Initial psychiatric evaluations are among the most critical components of mental health care. They serve as the foundation for diagnosing, creating treatment plans, and establishing rapport with patients. However, for providers, navigating the billing process for these evaluations can be complex and time-consuming. Understanding the right CPT codes, documentation requirements, payer-specific policies, and compliance standards is essential for getting reimbursed correctly.
In this guide, we break down the latest billing guidelines for initial psychiatric evaluations with practical insights for psychiatrists, psychologists, PMHNPs, and other licensed mental health professionals.
What is an Initial Psychiatric Evaluation?
An initial psychiatric evaluation is a comprehensive assessment performed during a patient’s first encounter. It includes a review of psychiatric history, current symptoms, medical background, mental status examination, and risk assessments. Based on this information, providers develop a preliminary diagnosis and treatment plan. Therapists often face unique billing challenges. This overview breaks down key strategies for medical billing for therapists in private practice.
Common CPT Codes for Initial Psychiatric Evaluations
There are two primary CPT codes for billing initial psychiatric evaluations:
| CPT Code | Description | Used By |
| 90791 | Psychiatric diagnostic evaluation without medical services | Psychologists, therapists |
| 90792 | Psychiatric diagnostic evaluation with medical services | Psychiatrists, PMHNPs, MDs |
90791 is typically used by non-prescribing mental health providers (e.g., LCSWs, LPCs, psychologists), while 90792 is designated for prescribing providers such as psychiatrists, PMHNPs, or other medical doctors. Both codes are considered time-based but do not specify exact time thresholds. Reimbursement often depends on detailed documentation.
According to the American Psychiatric Association, thorough documentation must include:
- Reason for a visit and referral source
- History of present illness (HPI)
- Mental status examination (MSE)
- Relevant medical, psychiatric, and family history
- Preliminary diagnosis
- Treatment recommendations
Key Documentation Tips to Avoid Denials
Many initial evaluations get denied due to inadequate documentation. Here are some best practices:
- Indicate if the service includes medical decision-making (use 90792).
- Provide detailed patient history, including psychosocial context.
- Document assessment tools used (e.g., PHQ-9, GAD-7).
- Include risk assessments for suicide, violence, or self-harm.
- Record time spent with the patient, even if not strictly required.
- Summarize your clinical impression and outline the next steps.
Billing Considerations by Payer Type
Medicare
Medicare covers both 90791 and 90792, but the provider must be credentialed and authorized to perform the service. Medicare Advantage plans may require pre-authorization. Always check the MAC’s LCD (Local Coverage Determination) for updated documentation criteria.
Emergency sessions require precise coding and time tracking. Get it right with this billing guide for
90839 and 90840 crisis intervention codes.
Commercial Insurance
Policies vary significantly. Some plans bundle the evaluation with the first therapy session, while others require a separate code. Confirm whether pre-authorization is needed and verify if the patient has already received an initial eval elsewhere.
Medicaid
State-specific Medicaid programs often have their own rules. For example, some states limit how often 90791/90792 can be billed. Ensure your documentation matches state Medicaid billing manuals.
Alabama Mental Health Billing Tip:
Alabama Medicaid requires prior authorization for codes like 90837 and psych testing (e.g., 96130). Submitting without it can lead to full claim denials. Check out our Alabama Billing Services page to stay compliant and get paid faster.
How Many Times Can You Bill an Initial Evaluation?
Initial psychiatric evaluations are typically billed once per patient per provider. However, you can bill the code again under specific circumstances:
- A patient has not been seen in over three years (depending on the payer)
- Transfer of care to a new provider
- A significant change in a condition requiring full reassessment
Be cautious with repeat billing, and always justify the medical necessity.
Common Mistakes to Avoid
- Using the wrong code: Don’t bill 90791 if you’re a prescribing provider.
- Incomplete documentation: Missing elements like MSE or diagnosis can trigger audits.
- Ignoring pre-auth requirements: Always verify benefits first.
- Bundling errors: Don’t bill 90791/90792 alongside E/M codes for the same visit unless specifically allowed.
Real-World Case Example
A psychiatrist at a private clinic in Maryland billed 90792 for a new patient with bipolar disorder. She documented:
- Full psychiatric and medical history
- MSE and cognitive testing
- Medication history
- A 60-minute face-to-face interaction
- Diagnosis, risk assessment, and treatment plan
She also included ICD-10 code F31.81 (Bipolar II disorder) and noted her medical decision-making rationale. The claim was paid in full by Aetna within 14 days, thanks to complete and structured documentation.
Just starting with testing services in private practice? Make sure you’re coding properly with this guide on psychological testing services.
Why Billing Correctly Matters
Incorrect billing leads to denials, delays, and audits. For solo and small group practices, this can mean thousands in lost revenue. Global Tech Billing LLC has seen firsthand how proper documentation and accurate code selection reduce denial rates by over 30% in mental health claims.
Additionally, understanding initial eval codes helps in forecasting revenue and identifying gaps in service delivery. Providers can track intake trends and optimize scheduling to improve operational efficiency.
Final Thoughts
Billing for psychiatric evaluations isn’t just about codes—it’s about clear communication, risk mitigation, and revenue preservation. By staying up to date with the latest CPT guidelines and payer rules, mental health providers can protect their income and streamline care.
At Global Tech Billing LLC, we help therapists, psychiatrists, and multidisciplinary clinics improve claim approval rates and simplify their revenue cycle. If your practice struggles with evaluation coding or denials, we’re here to support you.
Frequently Asked Questions (FAQs)
1. Can I bill both 90791 and 90792 for the same patient?
No. You should bill either 90791 or 90792 depending on your credentials. Billing both for the same session is not allowed unless a separate and medically necessary service is provided and documented.
2. Do I need pre-authorization for 90791 or 90792?
It depends on the payer. Medicare generally does not require it, but many commercial and Medicaid plans do. Always verify with the patient’s insurer before the appointment.
3. Can these codes be used for telehealth services?
Yes. Both 90791 and 90792 are covered for telehealth by many insurers, especially post-COVID. Confirm payer-specific telehealth policies and use the correct modifiers (e.g., 95, GT).
4. What’s the reimbursement rate for 90791 and 90792?
Rates vary by location and payer, but generally, 90791 reimburses around $140–$180, and 90792 reimburses around $160–$220. Check your payer’s fee schedule for exact figures.
5. How do I handle denials for initial evaluations?
First, review your documentation. If all elements are present and appropriate, file an appeal with supporting notes. If needed, Global Tech Billing LLC can assist in identifying the root cause and managing the appeals process.
