When and How to Bill CPT 90791 for Psychiatric Diagnostic Evaluation

When to Use CPT Code 90791

CPT 90791 is used for the initial psychiatric diagnostic evaluation without medical services.
This includes gathering a complete mental health history, assessing symptoms, and developing an initial treatment plan.

• •Duration: Typically 45–60 minutes
• •When to bill: The first visit for evaluation and diagnosis
• •Who uses it: Psychologists, licensed therapists, social workers, and other non-medical mental health professionals

Common scenarios:

• •First therapy session for a new patient
• •Comprehensive intake for depression or anxiety
• •Diagnostic assessment before starting psychotherapy

Insurance Verification Tips for CPT 90791

1. •Confirm coverage for mental health intake sessions under the patient’s plan.
2. •Verify the provider’s credentialing and license type are accepted by the payer.
3. •Check if a referral or authorization is required for the initial visit.
4. •Ensure documentation includes mental status exam, diagnosis, and treatment plan.

Example Case of CPT 90791

A licensed therapist conducts a 60-minute intake session for a new patient presenting with anxiety.
The therapist performs a full psychosocial history, identifies symptoms, and outlines a care plan.
One unit of CPT 90791 is billed for the diagnostic evaluation.