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Behavioral health billing can be complex and requires careful attention, especially when it involves initial psychiatric diagnostic evaluations. One such service is billed using CPT code 90791, which covers a comprehensive mental health assessment. However, billing errors are common when submitting claims for this service, leading to unnecessary denials and delayed reimbursements.
That's why the billing experts at MindCare have created this detailed guide to CPT code 90791. In this article, we'll explain the code's description, scenarios where it is applicable, relevant modifiers, and critical billing and reimbursement guidelines to help you submit accurate claims and receive timely payment.
CPT Code 90791 – Description
The official definition of CPT code 90791 is:
"Psychiatric diagnostic evaluation."
This code is used for an initial mental health assessment performed by a licensed clinician, such as a psychiatrist, psychologist, or clinical social worker. It involves:
- Collecting the patient's psychiatric and psychosocial history
- Evaluating the current mental health status
- Assessing medical, psychological, and social factors affecting the patient
- Developing an initial treatment plan or referral recommendations
Unlike other evaluation codes, 90791 does not include medical services, such as prescribing medications or performing a physical exam. It is focused on the psychological and diagnostic aspects of care.
The typical session lasts approximately 60 minutes, although it may vary depending on the patient's needs and the complexity of their case.
Scenarios Where CPT Code 90791 is Applicable
You would bill CPT code 90791 in the following situations:
Initial Psychiatric Assessment
When a new patient seeks care for the first time, a thorough mental health evaluation is necessary.
Example: A 32-year-old patient with symptoms of depression, anxiety, and insomnia undergoes a detailed interview, mental status exam, and history review before starting therapy or medication.
Transfer of Care
Even if a patient has been treated previously, a new provider often conducts a psychiatric diagnostic evaluation to gain a comprehensive understanding of the case.
Example: A patient moving to a new city establishes care with a new psychiatrist, who completes a comprehensive assessment before continuing treatment.
Re-evaluation After a Long Treatment Gap
When a patient has been out of treatment for an extended period, a new diagnostic evaluation is required to reassess the current mental health condition before resuming care.
Applicable Modifiers for CPT Code 90791
The following modifiers may be used with CPT code 90791 when needed:
- Modifier 95 – Indicates the psychiatric evaluation was conducted via telehealth.
- Modifier GT – Another telehealth-related modifier required by some payers.
- Modifier 59 – Identifies a distinct procedural service if other behavioral health services were provided on the same day.
- Modifier HO – Specifies that the provider is a master's-level clinician, if required by specific payers.
CPT Code 90791 – Billing & Reimbursement Guidelines
To ensure proper reimbursement for CPT code 90791, follow these key steps:
- Justify Medical Necessity
Document the reason for the evaluation. This includes:
- Patient's presenting symptoms or referral reason
- Relevant medical, social, and psychiatric history
- Mental status examination findings
- Diagnostic impressions and an initial treatment plan
- Use Accurate ICD-10 Codes
CPT 90791 should always be paired with the correct diagnosis codes. Examples include:
- F32.0 – Major depressive disorder, single episode, mild
- F41.1 – Generalized anxiety disorder
- F43.10 – Post-traumatic stress disorder, unspecified
- F90.9 – Attention-deficit hyperactivity disorder, unspecified type
- Be Aware of Frequency Limitations
Most payers reimburse CPT 90791 only once per patient per provider unless there is a valid reason for another evaluation, such as a transfer of care or a new episode of illness.
- Telehealth Billing
Many insurers now cover CPT 90791 for telehealth services, but payer-specific rules vary. Always check requirements for place of service codes, telehealth modifiers (95 or GT), and documentation.
- Understand Reimbursement Scenarios
Reimbursement depends on payer policies and settings:
- Private insurance often reimburses between $150 and $200 for in-person visits.
- Telehealth sessions usually receive the same rate if billed correctly.
- Medicare typically reimburses at slightly lower rates, ranging from $120 to $160, depending on the location.
- Always verify the payer's fee schedule to avoid underpayment.
Why Choose MindCare for Behavioral Health Billing?
MindCare offers unmatched expertise in behavioral health billing, a highly specialized yet often misunderstood area of medical billing. Our certified billing and coding specialists have a deep understanding of psychiatric and mental health documentation requirements, ensuring every claim is accurate, compliant, and optimized for maximum reimbursement. By eliminating costly errors and streamlining claim submissions, we help practices reduce denials and maintain seamless revenue cycles.
Our proven approach at MindCare delivers 100% accuracy and reliable results, leading to significant financial improvements for behavioral health providers. Many of our clients have experienced a 70% increase in revenue by leveraging our advanced billing strategies for high-volume mental health services. We manage the complexities of behavioral health billing, allowing you to focus entirely on delivering high-quality patient care. At the same time, we ensure your services are coded, documented, and reimbursed with the highest level of professionalism.
Let Mind Care Billing Help
We help mental health providers use the correct CPT codes, avoid denials, and get paid faster. If you're unsure which code to use, or tired of dealing with rejections, our team can take billing off your plate entirely.
Schedule a Free Consultation with Mind Care Billing today — and leave the coding confusion behind.
