Psychiatric Diagnostic Evaluation 90791 CPT Code
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It’s beneficial for mental health clinicians to have a good working understanding of psychotherapy CPT codes. Gaining a good grasp of the healthcare coding system can help you avoid costly delays in insurance reimbursements.
As a behavioral health provider, for example, you may need to perform a psychiatric diagnosis evaluation (90791 CPT code) when working with clients. To perform the evaluation, you’ll also need to know how the code is defined, as well as other critical components of healthcare billing.
This guide provides a comprehensive overview of the 90791 CPT code description, reimbursement rates, time requirements, and an explanation of the difference between CPT code 90791 & 90792.
What are CPT codes?
To understand the 90791 CPT code, you’ll first need to have a grasp of healthcare billing terminology and how to use it in your practice.
The American Medical Association (AMA) created the Current Procedural Terminology (CPT®) code set to describe healthcare procedures, along with surgical and diagnostic services.
Providers and healthcare professionals across the globe use CPT codes to ensure standardized language, which improves accuracy, streamlines reporting, and allows the tracking of health information.
Mental health clinicians use CPT codes for the purpose of insurance reimbursement.
90791 CPT code description
The 90791 CPT code description is a psychiatric diagnosis evaluation.
According to the Center for Medicare and Medicaid Services (CMS), the 90791 CPT code definition is an integrated biopsychosocial assessment that includes a full psychiatric and medical history, initial treatment plan and diagnosis, mental status exam, and an evaluation of the client’s condition and receptiveness to treatment.
Typically, a behavioral health provider performs an assessment as part of the initial intake appointment with the goal of making a clinical diagnosis.
After the initial assessment, if the client requires subsequent sessions, clinicians will use CPT codes 90834 and 90837. CPT code 90834 is for 45 minutes of psychotherapy with a patient, and CPT code 90837 is for 60 minutes of psychotherapy.
Mental health professionals who use the 90791 CPT code include licensed marriage and family therapists, clinical psychologists, licensed clinical social workers, licensed mental health counselors, and psychiatrists.
What is the difference between CPT code 90791 and 90792?
Both of these codes describe a psychiatric diagnosis evaluation. However, the key difference is that the 90791 CPT code is performed by a mental health clinician, whereas 90792 is performed by a licensed medical professional, like a psychiatrist.
CPT code 90792 includes medical services, such as prescribing medications or ordering laboratory tests, which can only be done by a psychiatrist or psychiatric nurse practitioner.
CPT code 90791 time requirement
CMS specifies that the 90791 CPT code time requirement is a minimum of 16 minutes, not to exceed 90 minutes.
However, you may be able to use add-on CPT codes, such as 99354 (for an additional 30 to 45 minutes of therapy) or code 99355 (for an additional 45 minutes).
90791 CPT code reimbursement rates
The reimbursement rates for 90791 CPT code vary depending on the facility, location, and provider.
For example, in Oregon as of April 2023, 90791 reimbursement rates range from $158.80 to $198.55.
CMS further specifies average reimbursement rates, based on the setting services are rendered:
- Non-facility reimbursement: $174.86
- Facility reimbursement rates: $150.80
- Non-facility limiting charge: $191.03
What are the 90791 CPT coding requirements?
CPT code 90791 relates to a psychiatric diagnosis evaluation. The CMS specifies that the complete biopsychosocial assessment must include:
- A mental health status examination
- Complete medical and psychiatric history
- Establishment of an initial diagnosis
- Evaluation of the patient’s ability and capacity to respond to treatment
- Initial plan of treatment
- Reported once per day and NOT on the same day as an evaluation and management (E/M) service
- Covered once at the outset of an illness or suspected illness
The coding requirements for the 90791 CPT code are also the same requirements for CPT code 90792.
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