How To Use CPT Code 90791

CPT 90791 describes the process of conducting a psychiatric diagnostic evaluation to determine a patient’s mental health condition. This article will provide an overview of CPT code 90791, including its official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes, and examples.

1. What is CPT Code 90791?

CPT 90791 is used to describe a psychiatric diagnostic evaluation performed by a healthcare provider to assess a patient’s mental health condition. During this evaluation, the provider collects information about the patient’s current and past behavior concerns, as well as their family, medical, and social history. Diagnostic tests may also be conducted to aid in making a diagnosis. This code is applicable to both new patients and patients undergoing re-evaluation.

2. Official Description

The official description of CPT code 90791 is a psychiatric diagnostic evaluation service. This evaluation involves the collection of information about the patient’s present and past behavior concerns, as well as their family, medical, and social history. Diagnostic tests may also be performed to work up the diagnoses. This code is used for new patients or patients undergoing re-evaluation.

3. Procedure

1. The healthcare provider conducts a comprehensive evaluation of the patient’s mental health condition.
2. Information is collected regarding the patient’s present and past behavior concerns, family history, medical history, and social history.
3. Diagnostic tests may be performed to aid in making a diagnosis.
4. The provider analyzes the collected information and formulates a diagnosis based on the patient’s symptoms and history.
5. A treatment plan is developed based on the diagnosis, which may include therapy, medication, or other interventions.
6. Follow-up appointments may be scheduled to monitor the patient’s progress and adjust the treatment plan if necessary.

4. Qualifying circumstances

CPT 90791 is used for patients who require a psychiatric diagnostic evaluation to assess their mental health condition. This code is applicable to both new patients and patients undergoing re-evaluation. The evaluation involves collecting information about the patient’s present and past behavior concerns, family history, medical history, and social history. Diagnostic tests may also be performed to aid in making a diagnosis.

5. When to use CPT code 90791

CPT code 90791 should be used when a healthcare provider performs a psychiatric diagnostic evaluation to assess a patient’s mental health condition. This code is appropriate for both new patients and patients undergoing re-evaluation. It should be reported only once per day, regardless of the number of sessions or time spent with the patient on the same day.

6. Documentation requirements

To support a claim for CPT code 90791, the healthcare provider must document the following information:

• Patient’s present and past behavior concerns
• Family history, medical history, and social history
• Diagnostic tests performed, if any
• Analysis of the collected information and formulation of a diagnosis
• Treatment plan based on the diagnosis
• Follow-up appointments scheduled, if applicable

7. Billing guidelines

When billing for CPT code 90791, ensure that the psychiatric diagnostic evaluation is performed by a qualified healthcare provider. This code should be reported only once per day, regardless of the number of sessions or time spent with the patient. It is important to note that CPT code 90791 should not be reported with other codes for the same evaluation.

8. Historical information

CPT code 90791 was added to the Current Procedural Terminology system on January 1, 2013. There have been no updates or changes to the code since its addition.

9. Examples

1. A psychiatrist conducting a comprehensive evaluation of a new patient’s mental health condition to determine a diagnosis and develop a treatment plan.
2. A psychologist performing a re-evaluation of a patient’s mental health condition to assess the effectiveness of the current treatment plan and make any necessary adjustments.
3. A licensed clinical social worker conducting a diagnostic evaluation of a patient with a history of trauma to assess the presence of post-traumatic stress disorder (PTSD) and develop an appropriate treatment plan.
4. A psychiatric nurse practitioner performing a comprehensive evaluation of a patient’s mental health condition to determine the need for medication management and therapy.
5. A licensed professional counselor conducting a diagnostic evaluation of a child with behavioral concerns to assess the presence of a specific disorder and develop an intervention plan.
6. A clinical psychologist performing a re-evaluation of a patient’s mental health condition to assess the progress made since the last evaluation and make any necessary adjustments to the treatment plan.
7. A psychiatric nurse conducting a comprehensive evaluation of a patient’s mental health condition to determine the appropriate level of care, such as inpatient or outpatient treatment.
8. A licensed marriage and family therapist performing a diagnostic evaluation of a couple experiencing relationship difficulties to assess the underlying issues and develop a therapy plan.
9. A psychiatric physician assistant conducting a re-evaluation of a patient’s mental health condition to assess the effectiveness of the current medication regimen and make any necessary adjustments.
10. A clinical social worker performing a comprehensive evaluation of a patient’s mental health condition to assess the presence of a mood disorder and develop an appropriate treatment plan.