CPT 90791 is the procedure code for the initial psychiatric diagnostic evaluation, the detailed diagnostic first visit that includes mental status exam, psychiatric history, diagnosis, and treatment planning. No minimum time required.

Quick Reference

Procedure Code: 90791
2026 Medicare Rate: ~$170–200
Typical Duration: 45–90 Min (No Minimum)
Visit Type: Initial Visit Only

What is CPT 90791?

CPT 90791, Psychiatric diagnostic evaluation, is the standard billing code for the initial psychiatric assessment of a new patient. It covers a thorough evaluation that includes psychiatric history, mental status examination, review of prior records when available, formulation of a diagnosis, and development of a treatment plan.

Unlike evaluation and management (E/M) codes, 90791 does not include medical services such as ordering labs or prescribing medication during the same visit. When a psychiatrist or other prescribing provider also performs medical services during the initial evaluation, the appropriate code is 90792 (psychiatric diagnostic evaluation with medical services). For follow-up psychiatric visits, use the psychotherapy add-on codes (90832/90834/90837) or the E/M codes (99213/99214) depending on the services provided.

CPT 90791 has no minimum time requirement. The AMA defines it by the clinical content of the service, a thorough psychiatric diagnostic evaluation, rather than by time. That said, most evaluations run 45–90 minutes due to the thoroughness required. Documentation must support the medical necessity and clinical complexity of the encounter.

Billing Disclaimer: Reimbursement rates and policies vary by payer, region, and plan year. Verify billing requirements with your payer and a qualified medical billing professional before submitting claims.

Who Can Bill CPT 90791?

90791 can be billed by a range of qualified mental health providers, subject to payer credentialing and state scope-of-practice rules:

Psychiatrists (MD/DO): Board-certified psychiatrists bill 90791 for the initial diagnostic evaluation. When medical services are also provided, use 90792 instead.
Psychologists (PhD/PsyD): Licensed psychologists can bill 90791 for initial psychiatric diagnostic evaluations. Payer credentialing as a behavioral health provider required.
LCSWs and LMFTs: Licensed clinical social workers and marriage and family therapists can bill 90791 when credentialed by the payer and working within their licensed scope of practice.
NPs and PAs: Nurse practitioners and physician assistants with behavioral health training can bill 90791. Psychiatric NPs commonly bill this code for initial evaluations. Verify payer-specific credentialing.

Telehealth note: CPT 90791 is on the Medicare telehealth services list. Append modifier 95 for live audio-video telehealth (most commercial payers and Medicare Advantage). Use modifier GT for traditional Medicare fee-for-service telehealth when required. Audio-only telehealth coverage for 90791 varies by payer, verify before billing.

What CPT 90791 Includes

Mental Status Exam: Appearance, behavior, speech, mood, affect, thought process and content, perception, cognition, insight, and judgment.
Psychiatric History: Chief complaint, history of present illness, past psychiatric history, medical history, family psychiatric history, social and developmental history.
Diagnosis: DSM-5-TR diagnostic formulation based on the evaluation findings, including differential diagnosis considerations when appropriate.
Treatment Plan: Initial treatment recommendations including therapy modality, medication considerations (if within scope), referrals, and follow-up plan.
Risk Assessment: Documentation of suicidal ideation, homicidal ideation, self-harm risk, and any thorough safety planning when clinically indicated.
Not Included: Medical Services. Ordering labs, prescribing medications, or performing physical exams are NOT included in 90791. Use 90792 when medical services are also provided.

Code	Description	Visit Type	Common Use
90791	Psychiatric diagnostic evaluation (no medical services)	Initial only	First psychiatric assessment, diagnosis and treatment planning
90792	Psychiatric diagnostic evaluation with medical services	Initial only	Initial psych eval where prescribing MD also provides medical services
90837	Psychotherapy, 60 minutes	Follow-up	Individual therapy sessions, not for initial diagnostic evaluations
99214	Office or other outpatient visit, established patient, moderate complexity	Follow-up (established)	Follow-up psychiatric med management visits for established patients
96130	Psychological testing evaluation services, first hour	Testing	Psychological testing with formal interpretation, not a psychiatric eval
96127	Brief emotional/behavioral assessment per standardized instrument	Any	Brief screenings (PHQ-9, GAD-7), does not replace 90791

90791 can be billed alongside 96127 on the same date when a brief standardized screening instrument is also administered and scored as part of the evaluation. Append modifier 59 to 96127 when billing both on the same date.

Documentation Requirements for CPT 90791

Chief Complaint and HPI: Document the reason for the visit and history of present illness, onset, duration, severity, and relevant context for the psychiatric symptoms.
Mental Status Examination: A complete MSE is required. Document all standard domains: appearance, behavior, speech, mood, affect, thought process, thought content, perceptions, cognition, insight, and judgment.
DSM-5-TR Diagnosis: Record the diagnostic formulation and DSM-5-TR codes. Document the clinical reasoning supporting the diagnosis, including any differential diagnoses considered.
Treatment Plan: Document initial treatment recommendations, including therapeutic interventions, any medication considerations, referrals, and the follow-up plan.
Medical Necessity: The note must support the clinical necessity for a full psychiatric diagnostic evaluation. A brief check-in note will not support a 90791 claim.
Provider Credentials: The note must identify the rendering provider and confirm they are credentialed with the payer to provide psychiatric diagnostic evaluation services.

CPT 90791 FAQ

What is CPT code 90791?

CPT 90791 is the procedure code for a psychiatric diagnostic evaluation, the initial detailed diagnostic psychiatric assessment. It includes mental status examination, psychiatric history, diagnosis formulation, and treatment planning. It does not include medical services such as prescribing; use CPT 90792 when medical services are also provided in the same visit.

What is the difference between CPT 90791 and 90792?

Both codes cover the initial psychiatric diagnostic evaluation, but 90792 also includes medical services, such as reviewing labs, prescribing medication, or performing a physical examination. If a psychiatrist or other prescribing provider performs the initial psychiatric evaluation and also provides medical services during the same encounter, 90792 is the correct code. Non-prescribing providers (psychologists, LCSWs) always use 90791.

How often can CPT 90791 be billed?

CPT 90791 is intended for the initial psychiatric diagnostic evaluation. It is not a code for follow-up visits. It can be rebilled if a patient is seen for a new episode of care or returns after a significant absence (payer-defined), but repeated billing of 90791 for routine ongoing care will typically be denied. Use 90837 (psychotherapy), 99213/99214 (E/M), or 90833/90836 (psychotherapy add-ons) for follow-up psychiatric encounters.

What is the 2026 Medicare reimbursement rate for CPT 90791?

The 2026 Medicare reimbursement rate for CPT 90791 is approximately $170–200, representing roughly 3.5 RVUs. Rates vary by geographic locality using the Medicare Geographic Practice Cost Indices. Commercial insurers typically reimburse at higher rates. Confirm current rates using the CMS Physician Fee Schedule Look-Up Tool.

Yes. Licensed clinical social workers (LCSWs) can bill CPT 90791 when credentialed by the payer and providing services within their licensed scope of practice. Medicare covers 90791 for LCSWs billing independently. Some payers may have additional credentialing or supervision requirements, always verify with each payer before billing.

Can CPT 90791 be billed via telehealth?

Yes. CPT 90791 is included on the Medicare telehealth services list. For live audio-video telehealth, append modifier 95. For traditional Medicare fee-for-service, modifier GT may be required depending on the billing system and year. Audio-only telehealth coverage for 90791 is payer-dependent, it is covered for Medicare in some circumstances but not universally by commercial payers. Verify current telehealth policies with each payer.

Can CPT 90791 be billed with CPT 96127 on the same day?

Yes. When a clinician administers a validated behavioral health screening instrument (such as PHQ-9 or GAD-7) as part of the initial psychiatric evaluation and scores and documents the result, CPT 96127 can be billed alongside 90791. Append modifier 59 to CPT 96127 to indicate it is a distinct service. Payer policies vary, verify before billing both on the same claim.

What documentation is required to bill CPT 90791?

Documentation must support a thorough psychiatric diagnostic evaluation. Required elements include: (1) chief complaint and history of present illness, (2) complete mental status examination, (3) relevant psychiatric, medical, family, and social history, (4) DSM-5-TR diagnostic formulation, and (5) treatment plan. The note must be detailed enough to demonstrate medical necessity and clinical complexity consistent with an initial psychiatric evaluation.

What is the difference between CPT 90791 and CPT 99214?

CPT 90791 is an initial psychiatric diagnostic evaluation, it is a distinct psychiatric assessment code used for the first encounter. CPT 99214 is an evaluation and management (E/M) code for established patients with moderate complexity medical decision-making or 30–39 minutes of total time. Follow-up psychiatric medication management visits for established patients are typically billed under E/M codes (99213/99214) or psychotherapy codes (90833/90836/90837), not 90791.

CPT Code 90791: Psychiatric Diagnostic Evaluation Billing