CPT Code 90791 is one of the CPT codes most commonly used by licensed behavioral health providers. It is used as part of an integrated biopsychosocial assessment, this includes key details like the patient’s mental state, their history, and recommendations.

CPT Code 90791 is typically used for diagnostic evaluations that are related to new behavioral health concerns or illnesses. It’s usually billed for the initial intake appointment and evaluation that each new patient needs to go through at the start of the treatment process. Going forward additional appointments will use either code 90834 or 90837, depending on the length of the appointment.

CPT Code 90791 can be billed by a variety of mental health professionals. This includes Licensed Clinical Social Workers, Licensed Mental Counselors, Licensed Professional Counselors, Licensed Marriage Family Therapists as well as clinical psychologists, and psychiatrists.

Do Insurance Providers Require Authorization To Use CPT Code 90791?

CPT Code 90791 is typically used in a routine outpatient appointment, which usually doesn’t require prior authorization. Though some exceptions are depending on the patient’s health plan and some insurance provider’s procedural rules.

Some insurance providers will only grant a single authorization for CPT Code 90791. After that Code 90834 or 90837 will be used for any EAP sessions. So, when verifying a new patient’s coverage during the scheduling process, be sure to ask their provider about CPT Code 90791.

Does CPT Code 90791 Pay More Than A Standard Outpatient Session?

It’s worth noting that CPT Code 90791 usually pays more per outpatient session than Codes 90834 or 90837. Though the exact payment varies depending on the credentialing of the mental health provider, as well as the patient’s insurance plan. Most insurance providers allow it to be billed at +35-75% of the typical 90834 reimbursement rate or +10-50% of the Code 90837 reimbursement rate.

Are There Time Requirements For Using CPT Code 90791

The Centers for Medicare Services have specific requirements that require CPT Code 90791 to be at least 16 minutes and not more than 90 minutes in the designated session time, with 60-minutes being the typical standard.

Can CPT Code 90791 Be Used For Add-On CPT Codes For Time Based Billing?

In the case of a session that lasts more than 90-minutes, it’s recommended to use one or more of the following add-on codes.

  • You can use the Add-On CPT Code +99354 for a session that is only 30-45 minutes of time.
  • You can also use CPT Code 90791 with Code + 99354 Add-on if the session is between 90 and 120 minutes.
  • Add-On CPT Code +99355 for an additional 45 minutes of time in the session.
  • Use 90791 + 99354 + 99355 for long sessions of greater than 120 minutes.

How Often Can CPT Code 90791 Be Billed For A Single Client?

How often CPT Code 90791 can be used for an individual patient can vary depending on their insurance plan. If you aren’t fully aware of their level of coverage, it’s best to contact their insurance provider. With public health institutions like Medicare and Medicaid most coverage plans only allow CPT Code 90791 once per client per provider in any given year.

It’s also worth noting that some private insurance plans allow CPT Code 90791 to be used once in 6 months. So, it’s always a good idea to check the patient’s status when verifying their coverage.

What’s The Difference Between CPT Code 90791 & Code 90792?

There are many similarities between CPT Code 90791 and CPT Code 90792. Though they are not identical. CPT Code 90792 is defined as a psychiatric diagnostic evaluation code. Though it includes medical services administered by a physician. Essentially Code 90792 can only be used by a medically licensed professional like a credentialed psychiatrist.

How Does CPT Code 90791 Affect Reimbursement Rates?

The Center for Medicare Services notes the following reimbursement rates for CPT Code 90791 averages $145.00 for a psychiatric diagnostic interview performed by a licensed mental health provider in a session that lasts between 20 to 90 minutes. They also note that CPT Code 90792’s Reimbursement Rate averages $160.00 for a psychiatric diagnostic interview performed by a psychiatrist for a session that lasts between 20 to 90 minutes.

Though these 90791 reimbursement rates are determined by Medicare and are considered national average rates. They can vary depending on the location, demographic demand, and the specialty of the mental health provider. The rates for providers who are not a Ph.D. or MD will typically see a lower reimbursement rate.

What Are The CPT Code 90791 Coding Requirements?

Medicare notes that there are some special requirements necessary to use CPT Code 90791 as part of a complete initial mental health evaluation for a new patient who is seeking mental health services. This includes

  • A thorough mental status examination is performed
  • The patient’s ability and capacity to respond to treatment is evaluated
  • A complete medical and psychiatric history is collected and included
  • The recommendations in the initial treatment plan
  • Covered at the outset
  • The evaluation is part of a face to face meeting between the new patient and the provider

Avoiding Coding & Billing Errors By Outsourcing

Errors in how CPT codes are used can lead to severe delays in reimbursement and even increase your risk of experiencing a claim denial. Especially if CPT Code 90791 is used more than the patient’s insurance provider allows.

If you are a solo practitioner, or you have a small, yet growing, practice with limited administrative staff, then you likely have to wear a lot of different hats. Most mental health practitioners receive little to no formal training in medical coding and billing practices, which puts them at risk of suffering significant delays in their incoming revenue stream.

By outsourcing your medical billing needs to a third-party firm like Operant Billing Solutions, you can trust that specially trained experts are implementing all the correct codes. Including critical things like correctly using CPT Code 90791 whenever applicable.