CPT 90791 + ICD-10 F33.1: Major depressive disorder, recurrent, moderate
Psychiatric diagnostic evaluation billed with Major depressive disorder, recurrent, moderate — documentation requirements, denial reasons, modifiers, and reimbursement context.
CPT Code
90791
Psychiatric diagnostic evaluation
ICD-10 Code
F33.1
Major depressive disorder, recurrent, moderate
Compatibility Notes
Used for intake evaluation of a patient with a known or newly presenting recurrent MDD at moderate severity. F33.1 at intake implies a prior MDD episode is documented in the history. This is one of the most common intake diagnoses in outpatient therapy. Most payers process this without scrutiny.
Documentation Required
- ✓Comprehensive evaluation with mood episode history (current and prior episodes)
- ✓PHQ-9 in moderate range (10–14) at intake
- ✓Risk assessment including suicidal ideation
- ✓Family history of mood disorders
- ✓Treatment plan and modality recommendation
Common Denial Reasons
- ✗90791 billed more than once per year by same provider
- ✗Prior episode not documented to justify recurrent specifier
- ✗PHQ-9 inconsistent with moderate severity
Applicable Modifiers
Reimbursement Notes
OON UCR $175–$350. One of the most commonly processed 90791 combinations in outpatient mental health.
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