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90791 CPT Code - Description, Time, When & How to Use It

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Therapists use CPT code 90791 to bill for initial patient assessments in behavioral health. This code covers diagnostic evaluations for new mental health concerns and is typically used for the intake appointment. Subsequent sessions will utilize codes 90834 or 90837 depending on length, and crucially, 90791 can be billed by various qualified mental health professionals.

Here's an overview of when to bill the CPT code 90791 and when you should use it in your practice.

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What is the 90791 CPT Code?

Billing in behavioral health can involve specific codes that accurately reflect the services provided. One such code is CPT 90791. This code is used for initial patient assessments, typically during the intake appointment. It covers diagnostic evaluations for new mental health concerns, allowing therapists to assess a patient's condition and develop a treatment plan.

Flexibility for Different Providers: Notably, CPT code 90791 can be billed by a variety of qualified mental health professionals. This includes Licensed Clinical Social Workers, Licensed Mental Counselors, Licensed Professional Counselors, Licensed Marriage and Family Therapists, as well as clinical psychologists and psychiatrists. This flexibility ensures patients have access to a wider range of providers who can utilize this code for their initial assessment.

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How long should an intake Appointment be?

Intake appointments vary in length and can depend on the clinician. If you're using a third-party payor for your services, such as Medicaid, Medicaid states that the 90791 CPT code should be used for at least 16 minutes and no longer than 90 minutes.

It may be helpful to use an electronic health records system, as many of them track your sessions' start and end times for you. Others may have a paper notation system where they follow beginning and end times. No matter how you track your sessions, ensure you're consistent, organized, and billing the correct amount of time.

When and how do you use the CPT Code 90791?

When you bill for the day, if you had an intake appointment, which is often the first session, you will bill 90791 for intake appointments that lasted anywhere from 16-90 minutes. Ensure you're billing the face-to-face time with the client in session.

It's essential always to have a method to document the beginning and end of your intake appointments so you can keep track of those for billing purposes. Billing accuracy helps ensure you get appropriately reimbursed and helps have a standardized method for charting your services that other payor sources can easily read.

With 90791, you also want to ensure that you aren't billing this code if you're a provider that can provide a medical evaluation concurrently with an intake. 90791 is designated only for intake appointments without a medical evaluation component.

Mental health professionals can also use outside diagnostic information from family members or other individuals close to the client for the intake assessment. The CPT manual discusses gathering history, reviewing the client's mental status, and making recommendations.

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Mental health professionals can do various clinical duties in the first session; it's always wise to check with your applicable state laws and regulations regarding what can be provided in an intake session.

There are other CPT codes associated with other types of psychotherapy sessions. These are billed differently than the intake appointment. For example, individual psychotherapy appointments are billed with different codes depending on the length of the psychotherapy session.

You may continue to gather background information in a psychotherapy session and perform mental status exams as a psychotherapist in psychotherapy sessions; however, these are not billed the same when they are conducted in individual psychotherapy sessions.

Billing CPT code 90791 is a necessity for most mental health professionals. Using it correctly will help you stay organized and provide a frame of reference for future work with your client or clients.

Why is it essential to get the 90791 code right?

CPT codes were developed to give healthcare professionals a universal language to describe services provided to them. When others look at your progress notes or initial appointment notes, and you've billed 90791, many people will know or can quickly determine what service was provided.

Accuracy of mental health documentation is essential as it helps prevent fraud, enables you to get reimbursed appropriately from third-party payors, and helps protect the valuable services you provide. Proper documentation is necessary for most mental health professionals, and when it is done correctly, it can be a weight off your shoulders.

It informs others about the services a client needs and can help protect you if your records are audited. Many clinicians can find mental health documentation challenging or overwhelming, especially if you're a neurodivergent clinician. Luckily, there are various tools available that can help you get the job done right.

Billing 90791 in a Nutshell

Billing intake appointments doesn't have to be a headache or a source of stress. While the CPT codes can be confusing for different services, 90791 is pretty straightforward. If you're completing a biopsychosocial assessment and this is your first session with a client, you will likely bill 90791.

The 90791 code encompasses various activities that a psychotherapist engages in. Most of the time, gathering background information and goal-setting are the critical goals for an intake session. A therapist can recommend where to begin therapeutic work to a client at the end of an intake session. Keeping track of your intake session, taking thorough notes, and asking clarifying questions will be standard through an intake appointment.

If you hope to make documentation and billing less stressful, consider trying what Mentalyc offers. Mentalyc is an AI-generated program that helps you write your progress notes for you. You can even write intakes with Mentalyc, leaving you more time to focus on your clients without trying to capture every little detail.

It's HIPAA-compliant and allows you to customize your notes and intakes to suit your needs. If you want to try Mentalyc, you can sign up here.

Let Mentalyc AI Write Your Progress Notes Fast

✅ HIPAA Compliant

✅ Insurance Compliant

✅ SOAP, DAP, EMDR, Intake notes and more

✅ Individual, Couple, Child, Family therapy types

✅ Template Builder

✅ Recording, Dictation, Text & Upload Inputs

References:

  • Centers for Medicare & Medicaid Services. (n.d.). Billing and Coding: Psychiatric Diagnostic Evaluation and Psychotherapy Services.


About the author

Marissa Moore

Marissa Moore is a mental health professional who owns Mending Hearts Counseling in Southwest Missouri. She specializes in providing affirming counseling services to the LGBTQIA+ community. Marissa has 11 years of experience working in the mental health field, and her work experience includes substance use treatment centers, group homes, an emergency room, and now private practice work.

Learn More About Marissa

Disclaimer

All examples of mental health documentation are fictional and for informational purposes only.

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