CPT Code 90791 is used for a psychiatric diagnostic evaluation without medical services. This is typically the initial assessment performed by a mental health provider when a new patient begins treatment.
Unlike therapy session codes, 90791 focuses on evaluating the patient’s mental health status, history, and treatment needs. It is an essential part of building a clinical picture and determining the next steps in care.
What Is CPT Code 90791?
90791 represents a comprehensive diagnostic interview that may include interviews with family members, a review of medical and psychiatric history, and the use of mental status examination tools. It is performed by psychologists, therapists, and clinical social workers. If a psychiatrist or other medical professional performs the evaluation with medical services, they would typically use CPT 90792 instead.
The service does not require a specific duration, but sessions often last 60 minutes or more to cover the required components.
When to Use CPT 90791
Use this code when conducting a formal intake assessment for a new patient. The session should include gathering background, reviewing prior diagnoses, and forming a preliminary treatment plan.
It may also be used when a patient is re-evaluated after a long absence or significant change in condition.
Documentation and Reimbursement
Documentation should cover:
Reason for evaluation
Clinical observations
Mental status findings
Diagnosis and recommendations
Reimbursement typically falls between $120 and $160, depending on the payer. This is a one-time-per-provider service unless medically necessary for reassessment.
