Code: 90791
Description: Psychiatric diagnostic evaluation without medical services
Context: This code is used for an initial psychiatric evaluation of a patient without any medical services included. It typically involves a comprehensive assessment of the patient’s mental health, including their psychiatric history and present symptoms.
Guidelines for Proper Use
- Specific Use for Initial Psychiatric Evaluation: Apply 90791 for the initial comprehensive psychiatric assessment of a patient. This includes gathering a detailed psychiatric history and evaluating present mental health symptoms.
- Documentation of Comprehensive Evaluation: Ensure healthcare providers’ documentation includes detailed notes on the psychiatric evaluation, covering areas such as the patient’s mental status, psychosocial history, and any relevant personal and familial psychiatric history.
- Exclusion of Medical Services: Do not use 90791 if the evaluation includes medical services such as a physical examination or medication management. This code is strictly for the diagnostic evaluation.
- Applicability Across Settings: This code can be used in various settings, including outpatient clinics, private practices, or during initial consultations in a hospital setting.
- Compliance with Psychiatric Evaluation Protocols: Use 90791 in accordance with standard psychiatric assessment guidelines and protocols, as well as payer-specific rules.
Common Misuses of 90791
- Using for Follow-Up Sessions: Misuse occurs if 90791 is applied to follow-up or routine therapy sessions. This code is intended for the initial evaluation only.
- Inclusion of Medical Services: Applying 90791 for evaluations that include medical examinations or interventions is inappropriate, as this code is for diagnostic evaluations without medical services.
- Inadequate Documentation of Evaluation: Not providing a comprehensive overview of the psychiatric evaluation can lead to misuse of this code.
