How Often Can You Bill CPT Code 90791?

Understanding the specific guidelines for Current Procedural Terminology (CPT) codes is essential for healthcare providers, particularly for services involving comprehensive patient assessments. Accurate billing ensures compliance with regulations, helps prevent claim denials, and facilitates timely reimbursement. This understanding is especially important for codes representing initial evaluations, as their billing frequency is often subject to strict rules.

Psychiatric Diagnostic Evaluation Code 90791

CPT code 90791 designates a psychiatric diagnostic evaluation without medical services, serving as a comprehensive assessment of a patient’s mental health condition. This code is typically used for the initial intake session with a new patient or an established patient presenting with new behavioral health concerns. The evaluation generally includes a detailed patient history, a mental status examination, and the formulation of a diagnosis. Providers also develop treatment recommendations based on the assessment findings.

This service involves a face-to-face encounter with a qualified healthcare professional, such as a psychiatrist, psychologist, licensed clinical social worker, or licensed professional counselor. While CPT code 90791 is not time-specific, these evaluations typically last between 45 to 60 minutes.

Standard Billing Frequency for 90791

In most cases, CPT code 90791 is considered a “once per lifetime” service for a given patient by the same provider or within the same provider group, or once per episode of care for a particular condition. Many insurance providers, including Medicare and Medicaid plans, typically allow CPT code 90791 to be billed only once per client, per provider, per year. Some private insurance plans might permit billing this code as frequently as once every six months. Subsequent visits for ongoing care, such as psychotherapy or medication management, are typically billed using different CPT codes, like psychotherapy codes (e.g., 90834 or 90837) or Evaluation and Management (E/M) codes.

Justifying Additional Evaluations

While CPT code 90791 is typically a one-time service, it can be billed more than once for the same patient under limited circumstances. These exceptions require robust documentation of medical necessity. One scenario involves a significant change in the patient’s clinical condition or presentation that necessitates a complete re-evaluation of their diagnosis and treatment plan, marking a new episode of care. For instance, if a patient experiences a severe psychiatric crisis or develops a new, distinct psychiatric diagnosis, a new comprehensive diagnostic workup may be justified.

Another situation for an additional evaluation is when a patient returns to care after a prolonged absence, such as six months or more. In these cases, their previous diagnostic evaluation might no longer be relevant due to significant life changes, medical developments, or the natural progression of their condition. If a patient transfers to a new provider or practice, the new provider may also need to conduct their own comprehensive initial evaluation to establish care, especially if prior evaluation records are unavailable or insufficient.

Supporting Documentation for 90791 Claims

Thorough clinical documentation is crucial for any CPT 90791 claim, especially when billing for an additional evaluation. The patient’s medical record must clearly demonstrate the medical necessity of the service. Essential elements include a comprehensive psychiatric history, covering the presenting problem, history of present illness, past psychiatric history, family history, and social history. A detailed mental status examination, a clear diagnostic formulation, and a risk assessment are also required.

The documentation must also outline a detailed treatment plan, including specific goals, proposed interventions, and a prognosis. For additional evaluations, the notes must explicitly state the reason for the re-evaluation. This justification should explain how the current evaluation differs from previous ones and why a new comprehensive diagnostic service was medically necessary. Adherence to these standards helps prevent claim denials and supports the billing process.

Payer-Specific Billing Considerations

While general CPT guidelines for code 90791 exist, specific payers, including Medicare, Medicaid, and commercial insurance companies, often have unique policies. These policies may include varying medical necessity criteria, frequency limitations, or prior authorization requirements. Some insurance companies might require authorization for all mental health services, while others might limit the number of visits without specific approval.

Providers should consult each payer’s specific billing manual or policy for accurate and current information. Payers may interpret “initial” or “new episode of care” differently, impacting how frequently CPT code 90791 can be reimbursed. Remaining informed about these variations helps ensure compliance and optimizes reimbursement.