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90791 CPT Code Documentation Requirements: Templates and Tips

Michael Reider

Apr 1, 2025

A 90791 CPT code pays an average of $145 per session, making it one of the best-paying codes for outpatient behavioral health services. But you need proper documentation and must follow specific billing guidelines to get paid.

This code applies to diagnostic evaluations for new patients and covers behavioral health assessments that last 16 to 90 minutes. On top of that, you must document several key elements to support your claims. These include the patient's presenting problem, mental status exam, medical history, and treatment recommendations.

We'll show you everything in this piece about documentation requirements, templates, and practical tips. This will help your 90791 claims meet compliance standards and prevent denials.

Understanding the 90791 CPT Code Description

The CPT code 90791 represents a complete psychiatric diagnostic evaluation that forms the foundations of mental health treatment. First introduced in 2013 among code 90792, these codes took the place of previous psychiatric diagnostic evaluation codes 90801 and 90802.

Definition and scope of psychiatric diagnostic evaluation

The 90791 CPT code defines an "integrated biopsychosocial assessment, including history, mental status, and recommendations" [2]. This evaluation gives a full picture of a patient's mental health status to set up a diagnosis and treatment direction. The evaluation also has "communication with family or other sources and review and ordering of diagnostic studies".

This psychiatric diagnostic evaluation collects a patient's complete medical and psychiatric history. The professional conducts a mental status examination and checks the patient's ability to take part in treatment. A tentative diagnosis and original treatment plan come from this evaluation [3].

Healthcare providers usually conduct a psychiatric diagnostic evaluation at the start of treatment or when they suspect an illness. In spite of that, patients might need another evaluation after a long break in treatment (about 6 months). They may also need one if they go to the hospital or if their mental status changes enough to need more assessment [4].

Difference between 90791 and 90792

The main difference between these similar codes shows up in the medical services part. Both codes cover psychiatric diagnostic evaluations. Code 90791 leaves out medical services, while 90792 specifically has them.

Medical services under code 90792 may involve:

Writing prescriptions
Performing physical examinations
Modifying psychiatric treatment

This difference makes code 90791 known as "psychiatric diagnostic evaluation without medical services." Code 90792 stands for "psychiatric diagnostic evaluation with medical services" [5].

Who can bill using this code

Several mental health professionals can bill using the 90791 CPT code [2]:

Licensed Clinical Social Workers (LCSW)
Licensed Professional Counselors (LPC)
Licensed Mental Health Counselors (LMHC)
Licensed Marriage and Family Therapists (LMFT)
Clinical Psychologists (PhD or PsyD)
Psychiatrists (MD)

Unlike this broad eligibility, code 90792 is restricted to medically licensed professionals like psychiatrists because it includes medical services [6]. Professionals who cannot write prescriptions use code 90791. Those who can prescribe typically use 90792 [6].

You should check your state's specific rules especially when you have Medicare and Medicaid. Some states might limit reimbursement for non-psychiatrists.

Documentation Requirements Across Payer Types

Your success with 90791 CPT code reimbursement depends on meeting specific documentation standards set by different payer types. Meeting these requirements will give a guaranteed payment and protect you during audits.

Medicare documentation standards

Medicare has strict documentation requirements for psychiatric diagnostic evaluations. Your documentation for the 90791 CPT code must include:

Complete medical and psychiatric history
Thorough mental status examination
Evaluation of the patient's response to treatment
Original treatment plan with measurable objectives
Reason for evaluation or chief complaint
Relevant family history and social history

Medicare states that "every page of the record must be legible and include appropriate patient identification information" [7]. Your documentation should support the ICD-10-CM codes you select and describe the service performed. You must record either start and stop times or the total session duration for time-based services [7].

Private insurance requirements

Private insurance requirements usually follow Medicare guidelines but might have their own specifications. The Mental Health Parity and Addiction Equity Act requires mental health service coverage comparable to physical health coverage [8].

Private insurers might:

Limit how often you can bill 90791 (typically once per 6 months)
Need diagnosis codes with initial session documentation
Use their own documentation templates

On top of that, some private insurers require psychiatrists and other mental health providers to bill using only psychiatric codes (90801-90899) instead of E/M codes [9].

Medicaid-specific documentation

Medicaid programs follow Medicare guidelines but often add requirements specific to each state. Medicaid clearly states that sessions should last between 16-90 minutes for the 90791 CPT code.

Medicaid also needs:

A diagnosis or provisional diagnosis in the first session
Documentation of session start/stop times or total minutes
Clear proof of medical necessity
Summary of diagnosis, functional status, and treatment progress

So, keeping accurate documentation "helps prevent fraud, enables you to get reimbursed appropriately from third-party payors, and helps protect the valuable services you provide".

Creating Audit-Proof Documentation

Creating bulletproof documentation for the 90791 CPT code needs specific elements to satisfy auditor requirements. Medicare guidelines state that healthcare providers must keep all documentation in the patient's medical record and make it available when asked.

Medical necessity documentation

Your documentation should show why the psychiatric diagnostic evaluation was needed clinically for the 90791 CPT code. Each patient record needs:

Detailed clinical notes about the patient's presenting problem
Complete mental status examination results
Assessment of the patient's response to treatment potential
Original treatment plan with clear objectives

Missing assessment components and incomplete notes often lead to claim denials. Your documentation should "tell the full story of the patient and the care they received."

Supporting the biopsychosocial assessment

Biopsychosocial assessments are the foundations of the 90791 CPT code. This integrated assessment should give a complete evaluation of:

Biological factors: Medical history, physical conditions, genetic predispositions
Psychological factors: Thought processes, behaviors, emotional states
Social factors: Relationships, cultural influences, socioeconomic status

You should document all relevant collateral contacts and list resources or referrals provided during the assessment to ensure accuracy and compliance.

Documentation retention policies

Medical record retention requirements vary by state. HIPAA doesn't specify retention timeframes, but most states require providers to keep records for at least seven years after therapy ends. Minor patients' records need to stay on file for seven years past their 18th birthday.

Electronic signature requirements

Healthcare providers can use electronic signatures for 90791 documentation if they include:

Authentication safeguards against modification
Clear identification as an electronic signature
Date and timestamps with printed statements (e.g., "electronically signed by")

The electronic signature must come from the actual provider who performed the service. This provider bears responsibility for the signature's authenticity.

Technology Solutions for Mental Health Documentation

Advanced technology provides solutions that can reduce the administrative burden of 90791 CPT code documentation by more than 70%. These digital tools optimize workflows and help your documentation meet compliance standards.

EHR templates for 90791

Electronic Health Record (EHR) systems now come with specialized templates built for the 90791 CPT code. These templates include all required documentation elements and ensure complete coverage during original psychiatric evaluations. The best ways to implement EHR templates include:

Same-day documentation completion policies
Regular documentation audits
EHR optimization for psychiatric practices [12]

Research shows that template-based documentation can substantially improve time management by breaking down the evaluation process into three phases: pre-session review (15 minutes), clinical interview (50-60 minutes), and documentation/planning (20-30 minutes) [12].

Digital assessment tools integration

Your workflow becomes more effective when you add standardized assessment tools. Digital versions of key assessment measures cut down paperwork and boost diagnostic accuracy. These tools include:

DSM-5 cross-cutting symptom measures for complete mental status assessment
Severity measures that match specific disorder criteria
Digital versions of standardized tests like the Drug Abuse Screening Test (DAST-10) and General Anxiety Disorder assessment (GAD-7) [13]

Digital assessments allow up-to-the-minute data sharing between behavioral health teams and make collaboration and care coordination simple [14].

Automated compliance checking features

Advanced compliance verification stands out as a valuable technological breakthrough. AI-powered systems now:

Scan progress notes to verify regulatory adherence
Flag potential compliance issues immediately
Lower the risk of claim rejections and audit penalties

These systems blend with existing EHR platforms and ensure secure patient data exchange while maintaining HIPAA compliance [14]. Advanced data analytics tools monitor compliance metrics continuously and spot potential problems before they escalate [15].

Conclusion

Your success with CPT code 90791 reimbursement and compliance depends on quality documentation. Medicare, Medicaid, and private insurers have different rules, but some elements stay consistent for all payers. These include detailed biopsychosocial assessments, mental status examinations, and clear treatment recommendations.

Modern technology has made documentation substantially easier. Mental health professionals can now focus more on patient care than paperwork, thanks to electronic health record templates, digital assessment tools, and automated compliance checking. These tools also help reduce errors and ensure your documentation contains all required elements.

Documentation does more than just secure reimbursement. It protects you during audits and supports care continuity while showing your services' value. Better patient outcomes emerge from detailed original evaluations that build a strong foundation for successful treatment.

FAQs

What are the key documentation requirements for CPT code 90791?

The documentation for 90791 should include a comprehensive biopsychosocial assessment, detailed mental status examination, medical history, presenting problem, treatment recommendations, and an initial treatment plan. It's crucial to record the exact time of the session and include the provider's name, signature, and credentials.

Who can bill using the 90791 CPT code?

Various mental health professionals can use the 90791 code, including Licensed Clinical Social Workers, Licensed Professional Counselors, Licensed Mental Health Counselors, Licensed Marriage and Family Therapists, Clinical Psychologists, and Psychiatrists. However, it's important to verify specific state regulations, particularly for Medicare and Medicaid billing.

How does CPT code 90791 differ from 90792?

The main difference is that 90791 is for psychiatric diagnostic evaluation without medical services, while 90792 includes medical services. Code 90791 is typically used by non-prescribing professionals, whereas 90792 is used by medically licensed professionals like psychiatrists who can prescribe medications.

Can 90791 be billed for telehealth services?

Yes, 90791 can be used for telehealth services. However, some payers may have specific requirements for telehealth billing, so it's important to check with individual insurance providers for their guidelines.

How can technology improve documentation for the 90791 CPT code?

Technology solutions like EHR templates, digital assessment tools, and automated compliance checking features can significantly streamline the documentation process for 90791. These tools can help ensure all required elements are included, improve time management, enhance diagnostic accuracy, and reduce the risk of claim rejections and audit penalties.