Summary & Overview
CPT 90791: Psychiatric Diagnostic Evaluation
CPT code 90791 represents the initial psychiatric evaluation, a critical service in mental health care that enables providers to diagnose and develop treatment plans for patients presenting with psychiatric symptoms. This code is widely recognized and reimbursed by major national payers, including Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. The psychiatric evaluation is typically conducted in an office setting and is essential for establishing a clinical baseline for conditions such as major depressive disorder, generalized anxiety disorder, bipolar disorder, and schizophrenia.
This publication provides a comprehensive overview of 90791, including payer coverage, clinical context, and related billing codes. Readers will gain insight into national benchmarks, policy updates, and the role of psychiatric evaluations in the broader landscape of mental health services. The analysis also highlights common modifiers and associated provider taxonomies, offering clarity on documentation and billing practices. By understanding the scope and significance of 90791, stakeholders can better navigate the complexities of psychiatric service reimbursement and clinical workflow.
CPT Code Overview
CPT code 90791 is used for a comprehensive psychiatric evaluation performed by a provider to assess and diagnose mental health conditions. This service is classified under psychiatry/psychological evaluation and typically takes place in an office setting (Place of Service 11). The evaluation involves gathering a detailed history, conducting a mental status examination, and formulating a diagnostic impression to guide further treatment planning. This code is foundational in mental health care, serving as the initial step in identifying and addressing psychiatric disorders.
Clinical & Coding Specifications
Clinical Context
A patient presents to a psychiatric provider's office (Place of Service 11) for an initial evaluation due to symptoms such as persistent sadness, anxiety, or behavioral changes. The provider, who may be a psychiatrist, psychologist, or mental health counselor, conducts a comprehensive psychiatric assessment to determine the patient's mental health status and establish a diagnosis. This evaluation may include a review of medical, psychiatric, and social history, mental status examination, and discussion of presenting concerns. The goal is to identify conditions such as major depressive disorder, generalized anxiety disorder, adjustment disorder, bipolar disorder, or schizophrenia, and to formulate a treatment plan.
Coding Specifications
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Modifiers:
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Modifier
25: Used when a significant, separately identifiable evaluation and management service is performed by the same provider on the same day as another procedure or service. -
Modifier
59: Indicates a distinct procedural service, used when procedures or services are not normally reported together but are appropriate under the circumstances.
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Provider Taxonomies:
Taxonomy Code Specialty Name 2084P0800XPsychiatry Physician 103T00000XPsychologist 101YM0800XMental Health Counselor
These taxonomies represent providers qualified to perform psychiatric diagnostic evaluations.
Related Diagnoses
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F32.9- Major depressive disorder, single episode, unspecified- Relevant for patients presenting with depressive symptoms requiring psychiatric evaluation.
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F41.1- Generalized anxiety disorder- Used when the patient exhibits persistent and excessive anxiety, warranting assessment.
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F43.23- Adjustment disorder with mixed anxiety and depressed mood- Applied when the patient has emotional or behavioral symptoms in response to a stressor, needing diagnostic evaluation.
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F31.9- Bipolar disorder, unspecified- Pertinent for patients with mood swings or episodes of mania and depression, requiring psychiatric assessment.
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F20.9- Schizophrenia, unspecified- Used for patients with psychotic symptoms such as delusions or hallucinations, necessitating a comprehensive psychiatric evaluation.
Each diagnosis code represents a clinical scenario where a psychiatric diagnostic evaluation (90791) is appropriate to establish the diagnosis and guide treatment.
Related CPT Codes
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90834- Psychotherapy, 45 minutes with patient- Used for ongoing psychotherapy sessions following the initial psychiatric evaluation.
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90837- Psychotherapy, 60 minutes with patient- Used for longer psychotherapy sessions, often after diagnosis and treatment planning.
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96130- Psychological testing evaluation services- Utilized when psychological testing is required to further clarify diagnosis or treatment needs, often in conjunction with or following the psychiatric evaluation.
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99213- Established patient office or other outpatient visit, typically 15 minutes- Used for follow-up visits for established patients, which may occur after the initial psychiatric evaluation.
These codes are commonly used together in a clinical workflow, with 90834 and 90837 representing ongoing therapy, 96130 for additional testing, and 99213 for routine follow-up. They may serve as alternatives or complements to the primary psychiatric evaluation code 90791.
National Reimbursement Benchmarks
Nationally, the mean rate for CPT code 90791 under Medicare is $178.67, while the average commercial benchmark (BUCA) is higher at $192.16. Among individual commercial payers, Cigna and UnitedHealth Group report the highest mean rates at $219.22 and $214.61, respectively, with Aetna and Blue Cross Blue Shield closer to the BUCA average.
Rate dispersion, measured by the difference between the 75th and 25th percentiles, varies significantly across payers. Medicare shows the tightest range at $9.00, indicating relatively consistent rates. In contrast, Cigna and UnitedHealth Group exhibit the widest dispersions, with ranges of $109.00 and $113.40, respectively, reflecting greater variability in commercial reimbursement.
The table and chart below present a detailed breakdown of national mean rates and percentile benchmarks for each payer.
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