CPT 90791 + ICD-10 F31.81: Bipolar II disorder
Psychiatric diagnostic evaluation billed with Bipolar II disorder — documentation requirements, denial reasons, modifiers, and reimbursement context.
CPT Code
90791
Psychiatric diagnostic evaluation
ICD-10 Code
F31.81
Bipolar II disorder
Compatibility Notes
Initial evaluation for Bipolar II disorder. The evaluation should document both hypomanic and major depressive episode history, distinguishing Bipolar II from Bipolar I and from unipolar depression. Substance use screening is critical. Most payers allow 90791 once per year without prior authorization.
Documentation Required
- ✓Comprehensive evaluation with hypomanic and depressive episode history
- ✓DSM-5 Bipolar II criteria documented
- ✓Substance use screen
- ✓Suicide and self-harm risk assessment
- ✓Medication management plan or referral
- ✓Psychotherapy treatment plan
Common Denial Reasons
- ✗90791 billed more than once per year by same provider
- ✗Hypomanic episode not documented
- ✗Evaluation reads like a therapy note
Applicable Modifiers
Reimbursement Notes
OON UCR $175-$350. Bill 90791 for all new patient intakes including Bipolar II.
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