Psychiatric Diagnostic Evaluation Billing Guide

Psychiatric Diagnostic Evaluations are foundational services used to assess a patient’s mental health condition and determine an appropriate treatment plan. Accurate billing depends on understanding the specific CPT codes and when each should be used.

There are only two psychiatric diagnostic evaluation codes:

90791 Psychiatric diagnostic evaluation
90792 Psychiatric diagnostic evaluation with medical services

CPT Code 90791

CPT code 90791 is typically used by psychologists, social workers, and other licensed behavioral health professionals. At the same time, 90792 is designated for psychiatrists, psychiatric nurse practitioners, and physician assistants, including medical services.

According to CPT, a psychiatric diagnostic evaluation involves an integrated biopsychosocial assessment, which includes the patient’s history, mental status examination, and clinical recommendations. It may also involve communication with family members or other sources and reviewing and ordering diagnostic studies.

CPT Code 90792 – Psychiatric Diagnostic Evaluation with Medical Services

This service involves an integrated biopsychosocial and medical assessment, which includes a review of the patient’s history, evaluation of mental status, relevant physical examination elements (as indicated), and clinical recommendations. The evaluation may also involve communication with family or other sources, prescribing medications, and reviewing and ordering laboratory or other diagnostic studies.

Reporting Psychiatric Diagnostic Evaluations More Than Once

CPT® further states that in some cases, someone other than the patient may be seen who provides the needed information, and that these codes may be billed more than once when two separate diagnostic evaluations are required. These evaluations may be reported more than once for a patient, if medically needed. This does not imply that all diagnostic evaluations should be conducted over two sessions, or that the practice should routinely bill two diagnostic evaluations at the start of treatment. A psychiatric diagnostic evaluation may be reported a second time on a patient if there has been a break in service or if a patient has recently been discharged from the hospital, and a new evaluation is required. CPT® states that this evaluation may be done in two different sessions on different days and reported twice if collecting information from another person is required. Although CPT® does not set a frequency limit, some payers may restrict usage.

Location and Coding Options for Psychiatric Evaluations

Psychiatric diagnostic evaluations can be performed in any location, including the office, emergency department, outpatient clinic, or inpatient unit. Depending on the nature of the encounter, medical psychiatric providers can bill either CPT code 90792 (psychiatric diagnostic evaluation with medical services) or an appropriate 

Evaluation and Management (E/M) service code.

E/M codes are selected based on the location and service type, from initial inpatient or observation services to emergency department visits, office-based consultations (new or established patients), and even nursing home or home visits. These codes fall within the standard scope of practice for medical providers.

However, using E/M codes for an initial psychiatric evaluation presents two key challenges:

1. Choosing the correct category of code (e.g., new vs. established patient, inpatient vs. outpatient).
2. Determining the appropriate level of service based on the complexity of the medical decision-making or the time involved.

Coding Considerations and Limitations for 90792 and E/M Services

CPT code 90792 does not include specific documentation requirements for a review of systems or a physical exam. However, this evaluation may be reported more than once if medically necessary, such as in the case of a hospital admission. Providers should be mindful of payer-imposed frequency limitations, which can result in claim denials.

When opting to use an E/M code instead of 90792, it's important to follow the specific documentation requirements for the selected level of service, including those outlined in the 1997 single specialty psychiatric exam guidelines.

Additionally, according to CPT, psychotherapy or psychotherapy for crisis services cannot be reported on the same day as a psychiatric diagnostic evaluation. Typically, time constraints prevent psychotherapy from being performed during the initial evaluation. Similarly, an E/M service cannot be billed on the same day as 90791 or 90792.

If psychotherapy is performed on the same day as an evaluation billed using E/M codes (99202–99215), the visit should be coded based on medical decision making, and a psychotherapy add-on code should be appended. Be sure to document a distinct section labeled “Psychotherapy” in the clinical note to support the claim.

Documentation Requirements for Psychiatric Diagnostic Evaluation

Documentation Requirements for Psychiatric Diagnostic Evaluations

A psychiatric diagnostic evaluation typically includes a thorough review of the patient's medical and psychiatric history, including past medical, family, and social history, a mental status examination, the establishment of an initial diagnosis, an assessment of the patient’s capacity and readiness for treatment, and the formulation of an initial treatment plan. Notably, an incomplete or missing treatment plan is a common reason for claim denials, and further guidance on this will be addressed in the psychotherapy section of this guide.

While time documentation is not required for psychiatric diagnostic evaluations, it’s important to use a template that ensures all required elements are addressed. According to CPT, this service involves an “integrated biopsychosocial assessment, including history, mental status, and recommendations.” In practice, this typically includes social and family history as well as details of any previous mental health treatment.

It's important to note that CPT does not permit billing psychotherapy or psychotherapy for crisis (90832–90839) on the same day as 90791 or 90792.

Streamline Your Psychiatric Diagnostic Evaluation Billing with BillingFreedom

At BillingFreedom, we ensure accurate and efficient mental health billing services for Psychiatric Diagnostic Evaluations (CPT 90791 and 90792). Our experienced team helps mental health professionals navigate the complexities of psychiatric billing, including interactive complexity codes (90785) and specific payer requirements. We ensure that every claim complies with CMS standards and private payer guidelines, reducing the risk of denials and delays.

With our expert support, providers can focus on patient care while we manage the billing process. From detailed documentation for biopsychosocial assessments to time-based therapy services, BillingFreedom ensures that every aspect of your psychiatric billing is handled accurately.

Trust us to streamline your billing, maximize reimbursement, and fully comply with industry regulations.

For more details about our exceptional mental health billing services, please don't hesitate to email us at info@billingfreedom.com or call us at +1 (855) 415-3472. 

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