CPT 90791 + ICD-10 F32.1: Major depressive disorder, single episode, moderate
Psychiatric diagnostic evaluation billed with Major depressive disorder, single episode, moderate — documentation requirements, denial reasons, modifiers, and reimbursement context.
CPT Code
90791
Psychiatric diagnostic evaluation
ICD-10 Code
F32.1
Major depressive disorder, single episode, moderate
Compatibility Notes
Initial evaluation where the patient presents with a first moderately severe depressive episode. The PHQ-9 score of 10-14 at intake supports the moderate specifier. This is one of the most common intake presentations in outpatient therapy. Bill 90791 for all new patient intakes.
Documentation Required
- ✓Comprehensive evaluation with first MDD episode documented
- ✓PHQ-9 in moderate range (10-14) at intake
- ✓Risk assessment including suicidal ideation
- ✓No prior depressive episodes documented (confirms single episode)
- ✓Treatment plan initiated
Common Denial Reasons
- ✗90791 billed more than once per year by same provider
- ✗Prior episode documented -- use F33.1 for recurrent moderate MDD
- ✗Evaluation note lacks diagnostic scope
Applicable Modifiers
Reimbursement Notes
OON UCR $175-$350. Bill 90791 for all new patient intakes.
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