Who Can Bill 90791? Provider & Payer Requirements
Master the comprehensive requirements for CPT code 90791. Understand provider eligibility, documentation standards, and critical payer guidelines.
CPT code 90791 designates a Psychiatric Diagnostic Evaluation, a comprehensive initial assessment for individuals seeking mental health services. This evaluation involves a mental health professional gathering extensive information to understand a patient’s concerns, establish a diagnosis, and develop a foundational treatment plan. Accurate billing and strict adherence to established guidelines are paramount for compliance and appropriate patient care.
Qualified Healthcare Professionals
Billing for a Psychiatric Diagnostic Evaluation (CPT code 90791) requires specific professional qualifications and licensure. Psychiatrists (MD/DO) are medical doctors specializing in mental health, assessing both mental and physical health aspects. Psychiatric-Mental Health Nurse Practitioners (PMHNPs) are also authorized, possessing specialized training to diagnose and formulate treatment strategies.
Licensed Clinical Psychologists (PhD/PsyD) are trained in assessment, diagnosis, and treatment of mental health disorders through psychological methods, including administering and interpreting psychological tests. Licensed Clinical Social Workers (LCSWs) provide diagnostic services, emphasizing psychosocial aspects and how social and environmental factors impact well-being.
Licensed Professional Counselors (LPCs) and Licensed Marriage and Family Therapists (LMFTs) are also authorized to conduct psychiatric diagnostic evaluations. LPCs focus on mental and emotional health, while LMFTs specialize in relational dynamics. The ability of these professionals to bill for 90791 depends on their state licensure and scope of practice.
Service Components and Documentation
A Psychiatric Diagnostic Evaluation (CPT code 90791) involves comprehensive information gathering and clinical assessment. This service begins with a thorough history, encompassing medical, psychiatric, social, and family background details. The medical history includes past illnesses and medications, while the psychiatric history details previous mental health concerns and treatments.
The evaluation requires a detailed mental status examination, assessing the patient’s appearance, mood, affect, thought processes, and cognitive function. A comprehensive assessment of presenting problems and symptoms is also conducted, exploring their onset, duration, severity, and impact on daily life and functioning.
A definitive diagnosis, utilizing standard classification systems like DSM-5-TR or ICD-10-CM, is required. Following diagnosis, a preliminary treatment plan is formulated, outlining initial interventions and referrals. A risk assessment must also be performed to identify potential for harm. Thorough documentation of all components is essential for medical necessity and continuity of care.
Payer Guidelines and Reimbursement
Successful billing and reimbursement for CPT code 90791 are significantly influenced by specific payer guidelines. These guidelines dictate which provider types an insurance plan recognizes and under what conditions they are credentialed for reimbursement. Payer policies vary considerably, impacting service viability.
Medicare recognizes psychiatrists (MD/DO), PMHNPs, LCSWs, and Clinical Psychologists for billing 90791. For other clinicians, “incident-to” rules may apply, meaning the service must be furnished under direct physician supervision and billed under the physician’s National Provider Identifier (NPI). This impacts who can bill and receive payment under Medicare, often requiring physician involvement.
State-level Medicaid programs exhibit significant variations in recognized provider types and billing requirements for 90791. Private insurance companies also have distinct policies, emphasizing provider credentialing and network participation. Contractual agreements define which provider types are covered for specific CPT codes, including 90791, and determine reimbursement rates.
Telehealth services for 90791 are common, but payer rules for remote services vary widely. Some payers have specific requirements regarding technology, patient location, or provider licensure in the patient’s state. These telehealth policies directly influence who can bill for 90791 when delivered remotely. Understanding these diverse payer-specific guidelines is essential for successful billing.