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CPT 90791

Psychiatric Diagnostic Evaluation

60-90 minutes
3.00 work RVU
5 requirements

Documentation Requirements

  1. 1Chief complaint and history of present illness
  2. 2Psychiatric history
  3. 3Mental status examination
  4. 4Diagnostic formulation
  5. 5Treatment recommendations

Billing Tips

  • •Use for initial psychiatric evaluations
  • •Not time-based
  • •Document comprehensive MSE

Frequently Asked Questions

What must be included in a 90791?

A complete 90791 requires: HPI, psychiatric history, substance use history, mental status examination, risk assessment, diagnostic formulation, and treatment plan.

Automate Psych Eval Documentation

Scribeable captures all required elements for CPT 90791 from your patient conversation. Generate compliant notes from the conversation itself.

Common Diagnoses

F32.9F41.9F90.9

Related Specialties

psychiatry

Related Procedures

CPT 908341.50 work RVU

Psychotherapy 45 min

CPT 961270.14 work RVU

Behavioral Screen

CPT 90791: Psychiatric Diagnostic Evaluation

Documentation Requirements

  1. Chief complaint and history of present illness
  2. Psychiatric history
  3. Mental status examination
  4. Diagnostic formulation
  5. Treatment recommendations

Billing Tips

  • Use for initial psychiatric evaluations
  • Not time-based
  • Document comprehensive MSE

Frequently Asked Questions

What must be included in a 90791?

A complete 90791 requires: HPI, psychiatric history, substance use history, mental status examination, risk assessment, diagnostic formulation, and treatment plan.

Related Procedures

  • CPT 90834: Psychotherapy 45 min
  • CPT 96127: Behavioral Screen

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