CPT 90791 + ICD-10 F32.9: Major depressive disorder, single episode, unspecified
Psychiatric diagnostic evaluation billed with Major depressive disorder, single episode, unspecified — documentation requirements, denial reasons, modifiers, and reimbursement context.
CPT Code
90791
Psychiatric diagnostic evaluation
ICD-10 Code
F32.9
Major depressive disorder, single episode, unspecified
Compatibility Notes
Used for initial evaluation of a patient presenting with a first depressive episode where severity has not yet been specified. F32.9 is appropriate as a placeholder diagnosis following the intake evaluation. Providers should update to a severity specifier in subsequent sessions.
Documentation Required
- ✓Comprehensive evaluation with mood episode history
- ✓PHQ-9 administered at intake
- ✓MDD criteria assessed and documented
- ✓Family history of mood disorders
- ✓Risk assessment including suicidal ideation
- ✓Treatment recommendations (therapy modality, medication referral if indicated)
Common Denial Reasons
- ✗90791 billed more than once per benefit year by the same provider
- ✗Evaluation note lacks the scope expected for a diagnostic evaluation
- ✗Severity specifier should have been assigned — F32.9 may prompt specificity request
Applicable Modifiers
Reimbursement Notes
OON UCR $175–$350. Bill 90791 for every new patient intake; it is the highest-reimbursed session code available for outpatient therapists.
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