CPT 90791 + ICD-10 F41.9: Anxiety disorder, unspecified
Psychiatric diagnostic evaluation billed with Anxiety disorder, unspecified — documentation requirements, denial reasons, modifiers, and reimbursement context.
CPT Code
90791
Psychiatric diagnostic evaluation
ICD-10 Code
F41.9
Anxiety disorder, unspecified
Common Modifiers
Compatibility Notes
Appropriate when the initial evaluation is establishing an anxiety diagnosis but the specific subtype has not yet been confirmed. F41.9 is a reasonable intake diagnosis when the differential is still open. Plan to refine the diagnosis within 1–2 subsequent sessions.
Documentation Required
- ✓Comprehensive evaluation covering anxiety symptom history
- ✓Anxiety disorder differential documented
- ✓GAD-7 or equivalent administered
- ✓Timeline for diagnostic clarification
- ✓Risk assessment
Common Denial Reasons
- ✗Unspecified code used as a permanent diagnosis without refinement planning
- ✗90791 billed more than once per year by same provider
- ✗Evaluation note lacks breadth for a diagnostic intake
Applicable Modifiers
Reimbursement Notes
OON UCR $175–$350. Even with an unspecified diagnosis at intake, 90791 is the appropriate code for the initial evaluation.
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