CPT code 90791 is the psychiatric diagnostic evaluation code used for a comprehensive initial intake assessment. It is the first-visit code — not a recurring session code — and it carries a meaningfully higher reimbursement rate than standard therapy codes.
What 90791 Covers
A 90791 visit is a thorough diagnostic interview in which the clinician gathers a complete psychiatric and psychosocial history, formulates a diagnosis, and establishes a treatment plan. It typically runs 60–90 minutes. The key feature is that it includes no medical services — if the clinician also prescribes medication or conducts a physical examination, CPT 90792 applies instead.
90791 vs 90792
- 90791 — Psychiatric diagnostic evaluation, no medical services. Used by therapists (LCSWs, LPCs, LMFTs, psychologists) and psychiatrists conducting a non-prescribing evaluation.
- 90792 — Psychiatric diagnostic evaluation with medical services. Used by prescribers (psychiatrists, NPs, PAs) who also order labs, review medications, or conduct a physical examination during the intake.
Non-prescribing therapists should always use 90791. Using 90792 without medical services is a billing error that can trigger a payer audit.
Typical Fee and Reimbursement
Private-pay fees for 90791 typically range from $150 to $300, reflecting the additional clinical depth required. Out-of-network insurance reimbursement follows the plan's UCR rate for the code — often higher than standard therapy codes because payers recognize the longer and more complex service. Medicare's 2025 national rate is approximately $164.
When You Can — and Cannot — Use 90791
90791 is appropriate only for the initial diagnostic evaluation. It is not appropriate to bill 90791 for:
- Ongoing therapy sessions, even if they involve reassessment
- Consultations in the middle of an established treatment relationship
- Routine session for an existing client after a break
Some payers allow a second 90791 after a prolonged absence (typically 2+ years) or a significant change in presentation requiring a fresh diagnostic formulation. Document the clinical rationale clearly.
Documentation Requirements
A compliant 90791 note should cover:
- Chief complaint and reason for referral
- Detailed psychiatric history, including prior diagnoses and treatments
- Social, family, developmental, and medical history
- Mental status examination
- DSM-5 diagnostic formulation with ICD-10 code(s)
- Initial treatment plan with goals and modality
On the Superbill
For intake appointments, generate a superbill listing CPT 90791 alongside the ICD-10 diagnosis code established at the evaluation. Superbilled handles this automatically — therapists enter the date, CPT code, and diagnosis, and clients receive a ready-to-submit PDF.