CPT Code 90791: Guidelines, Considerations, and Requirements

Are you getting mixed up with the CPT codes for your psychiatric evaluations? We’ve got your back as we will cover how you can accurately assign the 90791 code in this blog. Here, you will find lots of details like the authorization requirement, time length, add-on codes, and more.

We have also discussed the frequency of billing this code, the license levels associated, and the importance of accurately assigning it. In the end, you will also find some key guidelines and documentation requirements to follow. 

What Is CPT Code 90791?

The CPT code 90791 is maintained by the American Medical Association. It is a medical procedural code that comes under the Psychiatric Diagnostic Evaluation Services range. You can assign this code whenever you perform a psychiatric evaluation of your patient.

The difference between the 90791 and 90792 codes lies in who provides their medical services. The CPT code 90791 is used by psychologists, social workers, and other licensed behavioral health professionals. While, the CPT® code 90792 is used by psychiatrists, psychiatric nurse practitioners, and physician assistants.

The purpose of assigning this code is to make diagnoses for patients. The full form of CPT in medical coding is Current Procedural Terminology. This name is associated with specific numeric codes that are assigned to medical services.

Does CPT Code 90791 Require Authorization?

The 90791 code is considered a routine outpatient appointment. It means that authorization is generally not required.  But like any procedure code, exceptions do exist. They depend on the plan and insurance company.

Some insurance companies like United Health Care (UHC) will grant one authorization for 90791. They also grant a separate one for 90834 or 90837 EAP sessions. You must ensure that 90791 is covered if authorization is required.

You can find out if authorization is required by performing an eligibility and benefits verification. This verification has to be performed on the client’s insurance plan.

 Time Length for CPT Code 70901

The CMS requires 16 and 90 minutes of minimum and maximum time length respectively for 90791. However, they allow the usage of an add-on CPT code to designate session time.  Providers are recommended to spend at least 60 minutes in an intake session.

It can get tough conducting intake sessions for more than 90 minutes. You may have to get some external help in billing those sessions. You can simplify them by assigning accurate add-on codes to your claims.

Add-on CPT Codes for Billing 90791

A diagnostic interview session may exceed its standard time limit of 90 minutes. In such cases, you must bill the appropriate add-on CPT code along with the primary one. Add-on CPT codes reflect the extra time spent on a session. Below are the two key add-on codes that should be used based on the duration of a session.

• Add-On CPT Code +99354

This add-on code can be assigned to bill an additional 30-45 minutes. Its usage depends on the standard session length which should be between 90 and 120 minutes. There are many sessions that last between 1.5 to 2 hours. You can bill such sessions using 90791 + 99354.

• Add-On CPT Code +99355

It is also possible for a session to last between 2 and 3 hours. For such sessions, you can bill an additional 45 minutes using 90791 + 99354 + 99355. This code reflects the extended time spent beyond the initial 90 minutes and the first add-on.

What Is the Frequency of Billing 90791?

The frequency of billing the CPT code 90791 for individual patients is based on their insurance plans. Public health programs cover 90791 once per patient per provider within a calendar year. The two major public programs in the U.S. are Medicare and Medicaid.

However, there are some private insurance plans as well. They enable the usage of the CPT code 90791 once every six months. To avoid any issues with this code, you must always verify the coverage of your patients beforehand.

What Are the License Levels Required to Bill 90791?

Various licensed mental health professionals can bill the CPT code 90791. Those professionals include clinical social workers, professional counselors, and marriage family therapists. There are others as well like mental counselors, clinical psychologists, and psychiatrists.

You may not be eligible to perform diagnostic evaluations if you do not have these licenses. As a result, you cannot even specify mental health diagnoses for your patients.

Importance of Accurately Assigning 90791

CPT codes are assigned to serve as a universal language for healthcare providers. Your initial appointment notes and progress notes can be helpful for identifying them. Other professionals can look at them and determine your medical services.

Your mental health documentation should be accurate as well. It helps prevent fraud and ensures that you get reimbursed appropriately from third-party payors. By documenting your records correctly, you can lift a great weight off your shoulders.

Documentation is also an ideal informational resource for others about your medical services. It also protects you anytime your records are audited. Many clinicians can find documenting mental health challenging. However, there are various tools available that can get the job done.

Key Guidelines for Assigning CPT Code 90791

There are some key guidelines set that you must follow while assigning the CPT code 90791. Let’s take a look at them in detail:

• Diagnostic Evaluation

The CPT code 90791 is used exclusively for an initial psychiatric diagnostic evaluation. This code applies when a mental health professional conducts a thorough assessment of a patient. They assess the mental status of their patients.

Their cognitive functions, mood, behavior, thought processes, insight, and judgment are thoroughly assessed. The clinician also evaluates symptoms like depression, anxiety, psychosis, and other psychiatric disorders.

The patient’s medical, psychiatric, family, and social history is reviewed as well. This includes details about prior hospitalizations, previous diagnoses, and current medications. You also have to study the family history of mental health disorders.

After gathering all the necessary information, you can formulate a diagnosis. Then use that diagnosis to determine the most appropriate treatment plan. It is important to note here that the 90791 code does not involve psychotherapy.

If psychotherapy is part of the visit, you must bill your patients using a different code (e.g., 90832, 90834, or 90837). The 90791 code is strictly reserved for evaluations meant to establish a diagnosis and plan treatment. It is not applicable to therapeutic interventions.

• Multiple Practitioners

In some cases, a patient may be evaluated by more than one provider. There can be a psychiatrist involved along with a psychologist. This happens when multiple specialists diagnose a patient or establish a treatment plan.

The CPT code 90791 enables you to bill for the evaluation once. The condition is that you should conduct separate and distinct evaluations. For example, psychiatrists may focus on the medication needs and diagnoses of patients.

Whereas, psychologists may conduct psychological tests or assessments. This is often subject to the guidelines of insurance companies. Some payers may restrict billing multiple 90791 evaluations per episode of care.

Other payers may enable it as long as each provider performs a distinct evaluation. Therefore, it is critical to check the insurance plan of each patient. This will help you understand the rules for billing under such circumstances.

• Telehealth Use

You can also assign the CPT code 90791 for telehealth services. It enables mental health providers to conduct psychiatric evaluations remotely via video conferencing. They can be especially useful for patients who cannot attend in-person sessions.

Use modifiers to indicate that services are delivered remotely. There are specific telehealth modifiers that you can assign. The most commonly used ones are 95 and GT. The 95 modifier indicates that the services are provided via synchronous telecommunication.

This form of telecommunication is based on real-time audio and video. The GT modifier indicates real-time telehealth services. It is often used by Medicare and Medicaid. Keep in mind that not all insurers accept telehealth billing for psychiatric evaluations.

You must verify your patient’s coverage before providing services. Each insurance company may have different rules about using 90791 for telehealth. The documentation for telehealth services must meet the same standards as in-person evaluations.

It should reflect the detailed psychiatric diagnostic evaluations and clinical observations made. You must know that some payers have different coverage policies for in-person evaluations. This difference in policies can affect your reimbursements.

Documentation Requirements for CPT Code 90791

Healthcare providers must also fulfill certain requirements in terms of their documentation. We have listed some of those requirements below:

• Patient History

Collect relevant details about your patient’s developmental history. Also record possible substance use and any history of trauma or abuse. Note significant life events that may have an impact on mental health. Document any family history of psychiatric or psychological conditions.

Include information on the mental health history of parents, siblings, and other close relatives as well. Record any prior psychiatric diagnoses, treatments, hospitalizations, or medications. Include an overview of the patient’s physical health history for better psychiatric evaluations.

• Mental Status Examination

The MSE is a structured assessment of the patient’s current mental state. It provides insights into their cognitive, emotional, and behavioral functioning. It should include a comprehensive evaluation of various components.

One of the major components is insight and judgment. Note the patient’s understanding of their own mental health condition. You should also analyze their ability to make informed decisions. Document any impairments in judgment or lack of insight.

Another key component is positive and negative findings. Include them to confirm the patient’s reported symptoms. Your documents must also indicate the absent symptoms. For example, patients denying suicidal ideation should be noted as negative findings.

• Diagnostic Impressions and Clinical Assessment

Summarize the overall clinical pictures of your cases. Synthesize the information gathered from their history, MSE, and other relevant sources. This should provide a clear explanation of your impression of their mental health status. Use appropriate DSM-5 or ICD-10 codes as well to specify the diagnosis.

Include a rationale for the diagnosis. Consider the differential diagnoses and reasoning behind your choice. The diagnosis may not be fully established. In this case, you should state that it is provisional. You would also have to explain the additional details required to confirm it.

The Bottom Line

This blog delved into the CPT code 90791 and how you can accurately assign it. We covered its requirement of authorization, time length, and the add-on codes involved. We also discussed the allowed frequency of billing this code.

The license levels required to bill 90791 were highlighted as well along with the importance of accurately assigning it. In the end, we looked at the key guidelines and documentation requirements that must be fulfilled while assigning this code. Contact Health Quest Billing and unlock a wide range of medical coding services.