90791 CPT Code

90791 CPT Code (2022) Description, Guidelines, Reimbursement, Modifiers & Example

90791 CPT code is an “integrated biopsychosocial examination, comprising history, mental status, and recommendations,” according to the CPT code. The evaluation may also entail “contact with family or other sources, as well as review and ordering of diagnostic studies,” according to the guidelines.

90791 CPT Code Summary

The practitioner does a mental evaluation of the patient to make a diagnosis in this service. It was introduced in 2013, along with 90792, to replace the 90801 and 90802 psychiatric diagnostic assessment codes.

Psychiatrists, clinical psychologists, licensed professional counselors, licensed social workers, and licensed marriage and family therapists can utilize the code. However, specific states may not allow reimbursement for non-psychiatrists when charging Medicare and Medicaid, so verify your state’s rules first.

Mental diagnostic evaluations may code with 90791 CPT code, but medical treatments may code with CTP 90792. Everything from writing prescriptions to doing physical exams to altering psychiatric therapy includes medical services.

There are two ways to bill 90791 CPT code and 90792 with the interactive complexity code (90785), but only if they may provide on the same day as psychotherapy or an E/M (evaluation and management) session for the same patient.

Diagnostic evaluations that don’t involve providing medical services, like those involving discussions with family members or the examination of other assessments, can be coded under CPT code 90791

Additionally, the CPT service code 90834 (individual psychotherapy, 45 minutes) pays out more than other usual mental health CPT service codes like 908337 (group psychotherapy, 45 minutes) (individual psychotherapy, 60 minutes). Furthermore, in most situations, no prior consent is required (although some plans do require preauthorization, so be sure to check individual payer guidelines).

Psychological diagnostic testing and medical care (90792) To review and order diagnostic tests, as previously described (90791), family members or other sources may consult. The provision of medical care is a necessity. 

CPT code 90791 uses to bill for diagnostic evaluations, which may frequently perform in conjunction with an assessment visit. There will be a wide range of standards for each state in the United States, but they may be similar. In Minnesota, these are the diagnostic standards. The diagnostic criteria take the biopsychosocial aspects into account.

Diagnostic evaluation codes for psychiatric disorders have fewer options than E/M codes for brand-new patients (99201 to 99205). (90791, 90792; see the following section for more information.) In addition, there is a three-year waiting period for new patients who have not received professional services from this physician or another physician within the same group practice. 

90791 CPT Code Description

Beginning January 2013, various CPT codes for mental health were revised, including 90801. CPT code 90791 specifies an “integrated biopsychosocial examination, comprising history, mental status, and recommendations.” For reasons we’ll get to later, code 90791 is most often used for the initial intake appointment, even though it covers a wide range of evaluation types.

It’s common for practitioners to mix the two codes, which were both developed simultaneously. For example, medical services such as prescription writing are included in code 90792, although that is the only substantial difference between the two codes. Only psychiatrists and other medical professionals are permitted access to code 90792.

90791 CPT code is a well-liked option due to its adaptability and the large variety of examinations it covers. However, its use has some limitations, and you may have difficulty getting reimbursed if you don’t grasp them.

To begin, while some payers allow providers to bill this code every six months, most repay customers only once per year for the cost of using it. So, code 90791 uses for both initial evaluations and annual progress reports.

It’s all about the session’s content that governs the use of CPT code 90791. According to Medicare, each 90791-invoiced session must include (or have) the following characteristics:

  • A thorough medical and mental health history may gather.
  • Examining the state of your mind
  • The patient’s aptitude and capacity to respond to treatment will evaluate.
  • A new report may generate each day.
  • No specific day will mention because the same provider offers E/M service.
  • From the beginning, you’ll protect.

As with Medicare, most private payers follow the same rules and regulations. However, as each payer is unique, it’s good to check with each client’s insurer to see what criteria they apply before utilizing this code.

Even if family members are present, the patient may present for at least part of the session. Face-to-face is the only way to get it done. There are certain exceptions to the face-to-face requirement during the COVID-19 outbreak. Most private payers are also removing the need for face-to-face meetings with therapists as telemedicine becomes more widely available through Medicare and Medicaid.)

cpt code 90791

90791 CPT Code Billing Guidelines

CPT code 90791 can only be used once per year per patient and physician. Their insurance plan determines the number of times a patient can use CPT Code 90791. A better bet is to speak with their insurance carrier to confirm the extent of their coverage.

As a side note, some private insurance policies limit the usage of 90791 CPT code to once every six months. Therefore, checking the patient’s status is always good when determining insurance coverage.

It is common for CPT Code 90791 to pay more for each outpatient session than CPT Codes 90834 and 90837. However, the actual payment is dependent on the credentials and insurance plan of the patient’s mental health physician.

 An average reimbursement rate of +35-75% for Code 90834 or +10-50 percent of the reimbursement rate for Code 90837 may generally accept by insurance companies.

  • Use the Add-On CPT Code +99354 for 30-45-minute sessions.
  • CPT Code 90791 with code + 99354 Add-on may use if the session is between 90 and 120 minutes long.
  • To prolong the session by 45 minutes, use CPT Code +99355.
  • Dial 90791 + 99354 + 99355 for sessions that go longer than 120 minutes.

The 90791 examinations may complete by a clinician (such as a social worker), while a psychiatrist completes the 90792 assessment. This abides by the terms of the contract with the payer.

However, billing both codes on the same day raises questions from the payer about why two clinicians did the initial evaluation, and the payer may withhold reimbursement for both codes in that case.

A doctor could use the 90791 code, and a psychiatrist could use the E/M consult codes to get around this (99241-99245). Another option for the psychiatrist is to use the initial hospital care E/M codes (99221-99225), including consultation and an initial psychiatric evaluation. However, this would involve admittance to an inpatient psychiatric facility.

90791 CPT Code Modifiers

An HN indicates a bachelor’s degree, whereas an HP indicates a doctoral degree. To bill with the HO modifier, the supplier must have a master’s degree, and only if they do. If you use our billing service and are unsure whether or not a modifier is required, we can run a check on your behalf to determine which one to apply.

 Traditional mental health procedure codes like 91791, 91834, and 91837 may use to charge behavioral health specialists. The HO modifier may operate with any standard procedure code for mental health. It goes like this: 90791, 90834, 90837, etc.

The HP descriptor indicates that the provider is a clinical psychologist or doctoral-level practitioner in behavioral health. A master’s degree is denoted by HO, while HN denotes a bachelor’s degree.

 A billing service like TheraThink can help by contacting the insurance company and requesting information. State-specific UC modifiers indicate Medicaid level 12, which varies by state.

Providers are obliged to affix modifier UC to claims for spontaneous or elective deliveries of 39 weeks or fewer, as stated in section 8-10.4.2 of the Utah Medicaid Provider Manual for Physician Services (UtahMDPMS). 

As long as the phrase “UC” may not include in the claim, it will regard an early elective delivery of fewer than 39 weeks and 0 days. Health care providers need to make sure that they are billing for the correct diagnosis and procedure by using the appropriate codes and modifiers. “”

A doctor/NPP modifier (AF, AG, SA) will include with the claim to receive an additional payment for the physician (for both 90791 and 90792).

The modifiers for the CTP code 90791 are HO, HP, U6, UA, UB, UC

Reimbursement

According to the Center for Medicare Services, the typical payment rate for CPT Code 90791 is $145.00 for a 20- to a 90-minute psychiatric diagnostic interview conducted by a licensed mental health practitioner. They also mention that the typical reimbursement rate for a psychiatrist-conducted cognitive diagnostic interview lasting 20 to 90 minutes is $160.00 under CPT Code 90792.

Medicare sets these 90791 reimbursement rates, but they may represent all states. Various factors influence this, including location, population, and the type of mental health care provider. For example, reimbursement rates are typically lower for providers who do not hold a doctorate or a medical degree.

Examples

Customers of OMS can receive up to two diagnostic interviews as part of the 150-unit package of services. Only one first evaluation/diagnostic interview (90791/90792) may provide as part of the initial 12 non-OMS services. Some rendering providers may be linked with the same OMHC and practice group, while others may not. Consider that one of the providers is a physician and the other is not.

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2 Comments

  1. I am curious – some practices that I know about see the parents of the child client first and then the child alone and then the child with the family. All was part of the evaluation. Would the practice bill 90791 for each session in this case? How can they see the parents alone if 90791 is supposed to have the child present?

    1. Hi Marian,

      The guidelines now allow charging on consecutive days when a lengthy evaluation is medically required. Because an assessment of a child requires that both the child and the parents be seen together and independently, for institutionalized patients, Medicare will only cover one 90791 annually unless medical necessity can be proven for others.

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