CPT code 90791 is the standardized billing designation for a Psychiatric Diagnostic Evaluation without Medical Services. This code is used by healthcare providers to communicate the specific service rendered to insurance companies for reimbursement. It represents the comprehensive initial assessment performed by a mental health professional to understand a patient’s condition and develop a preliminary plan for care.
The Foundation of Psychiatric Care
The service represented by CPT code 90791 is an integrated biopsychosocial assessment, which is the necessary first step in establishing a diagnosis and formulating a treatment approach. This extensive evaluation involves gathering a complete history, including the patient’s psychiatric, medical, family, and social background. The clinician reviews current symptoms, functional status, and previous treatment attempts to form a thorough understanding of the patient’s mental health status.
A crucial distinction of the 90791 code is the phrase “without medical services,” meaning the evaluation does not include activities like prescribing medication or conducting a physical examination. This means the code is most frequently used when the service is provided by licensed mental health professionals who do not have prescriptive authority. Professionals such as Licensed Clinical Social Workers, Clinical Psychologists, and Licensed Professional Counselors typically use this code.
The output of this diagnostic evaluation is the establishment of a tentative diagnosis based on the information gathered and the clinician’s assessment of the patient’s mental status. This initial diagnosis and the resulting treatment recommendations, such as suggesting a specific type of psychotherapy, form the foundation for all subsequent care. If a provider offers medical services during this initial session, the evaluation is billed under the separate code 90792.
The Patient Experience During Evaluation
The psychiatric diagnostic evaluation is primarily a structured, in-depth clinical interview, often lasting between 45 and 90 minutes. This extended duration allows the provider enough time to conduct a comprehensive assessment that goes beyond the typical length of a follow-up therapy session. The session usually happens in a comfortable, confidential setting, establishing a safe environment for the patient to share sensitive information.
The provider guides the patient through a series of open-ended questions designed to explore the scope and severity of their current symptoms, including how they impact daily functioning, work, and relationships. The interview also covers the patient’s developmental history, past mental health treatments, and any history of substance use. In some cases, the professional may gather information from family members or other involved sources to gain a more complete picture, with the patient’s consent.
A significant part of the experience is the mental status examination, where the clinician observes and assesses the patient’s appearance, mood, thought process, and judgment. This observational component helps the professional formulate a clinical impression that informs the final diagnostic decision. By the end of the session, the provider typically discusses their initial diagnostic impressions and collaborates with the patient to set preliminary goals for treatment.
Navigating Insurance and Billing
CPT code 90791 is the administrative mechanism that enables the provider to submit a claim to the patient’s insurance carrier for the initial service. Because this code represents a comprehensive intake, it often has a higher reimbursement rate than standard ongoing therapy codes, reflecting the complexity and time investment of the diagnostic process. The code is generally intended to be billed only once per patient, per episode of care.
While some insurance plans may not require prior authorization for a routine outpatient diagnostic evaluation, patients should verify their coverage before the first appointment. Patients should inquire about their specific deductible, copayment, or coinsurance amounts that will apply to this CPT code. This verification step helps prevent unexpected out-of-pocket costs and confirms that the chosen provider is in-network.
The “without medical services” distinction also affects billing, as insurance coverage may vary based on the provider’s license and prescriptive authority. If a patient’s plan only covers the evaluation when performed by a professional with prescriptive authority, they may need to seek a provider who would use the alternate code 90792. Understanding these nuances ensures the claim is processed accurately and the patient receives maximum benefit coverage.