CPT® Code 90791 is used to report a psychiatric diagnostic evaluation performed by a physician or other qualified mental health professional. This code applies to an initial assessment of a patient’s mental health status, including their history, current symptoms, psychosocial factors, and treatment needs—without medical services such as prescribing or physical examination.
This code describes a comprehensive initial mental health assessment that includes gathering diagnostic information, conducting a mental status exam, and formulating an initial treatment plan. It is typically used once at the beginning of treatment or for a re-evaluation after a significant gap in care.
Key facts about CPT Code 90791
- Service type: Psychiatric diagnostic evaluation
- Provider type: Non-medical mental health providers (e.g., psychologists, social workers, counselors); physicians may use this code when not providing medical services
- Medical services included: None (no prescribing or physical exam)
- Typical duration: 60 minutes, though not time-based unless required by the payer
- Common uses:
- New patient intake
- Transfer of care assessments
- Diagnostic clarification
- Re-entry to therapy after a long gap
When to use CPT Code 90791
CPT 90791 is appropriate when performing an initial psychiatric assessment that involves evaluating mental health history, risk factors, presenting problems, and formulating clinical impressions. This service may include interviews with family members or caregivers if needed to support diagnostic understanding.
Providers should not use 90791 if the evaluation includes medical services such as physical exam or medication management—in such cases, CPT 90792 is more appropriate.
Documentation requirements
To properly support CPT 90791, the documentation should include:
- Reason for evaluation (e.g., depression, anxiety, trauma, behavioral concern)
- Psychiatric history and presenting symptoms
- Mental status examination findings
- Psychosocial and family history
- Clinical impressions or differential diagnoses
- Initial treatment plan or recommendations
If applicable, include information from collateral sources (e.g., parents, partners, other providers).
Reimbursement and coding considerations
CPT 90791 is widely reimbursed by commercial insurers, Medicaid, and Medicare. It is typically limited to one session per episode of care, though exceptions can apply for new concerns or returning patients after a long lapse.
Important considerations:
- Do not bill alongside other therapy or E/M codes on the same day
- Some payers require authorization or pre-certification
- Ensure that only qualified mental health providers render this service
- Time is not explicitly required, but most sessions last 45–60 minutes
Use diagnosis codes that accurately reflect the clinical issues being assessed, such as F32.0 (major depressive disorder, mild) or F41.1 (generalized anxiety disorder).
How OptiMantra supports behavioral health intakes
For therapists, psychologists, and integrative providers offering mental health services, OptiMantra provides a seamless platform to document, manage, and bill CPT 90791 efficiently and compliantly.
With OptiMantra, mental health providers can:
- Use custom intake templates tailored to 90791 documentation standards
- Record structured mental status exams and diagnostic impressions
- Auto-generate treatment plans that align with payer expectations
- Link clinical notes directly to billing workflows for faster claim submission
- Track previous 90791 usage to avoid duplicate billing or authorization issues
Whether you’re working solo or in a multidisciplinary group, OptiMantra ensures your patient evaluations are clinically thorough and billing-ready—without the admin burden.
Try OptiMantra for free here!
