CPT 90791 + ICD-10 F84.0: Autistic disorder
Psychiatric diagnostic evaluation billed with Autistic disorder — documentation requirements, denial reasons, modifiers, and reimbursement context.
Compatibility Notes
This combination covers the initial psychiatric or psychological evaluation for a patient with a known or suspected autism spectrum diagnosis. ASD evaluations are commonly covered by commercial plans, but scope of practice restrictions apply: psychologists and licensed clinical social workers can conduct the evaluation, but prescribing providers may need to be involved for a complete diagnostic workup. F84.0 is the ICD-10 equivalent of DSM-5's Autism Spectrum Disorder (Level 3 support needs, previously classic autism).
Documentation Required
- ✓Time spent in face-to-face evaluation (no time minimum, but must be a comprehensive intake)
- ✓Documented reason for evaluation referral and presenting concerns
- ✓Developmental and social history relevant to ASD diagnosis
- ✓Current DSM-5 ASD criteria assessed and documented
- ✓Standardized assessment tools used (e.g., ADOS-2, ADI-R, CARS) noted if applicable
- ✓Diagnostic impression with differential diagnosis considered
- ✓Treatment recommendations and referrals
Common Denial Reasons
- ✗Scope of practice issue — insurer may deny if the billing provider does not have documented expertise in ASD assessment
- ✗Duplicate evaluation — if a comprehensive ASD evaluation was completed recently, a second 90791 may be denied
- ✗Missing developmental history documentation
- ✗F84.0 used when F84.1 (Atypical autism) or a different F84.x code would be more accurate
Applicable Modifiers
Reimbursement Notes
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