A new client sits down, you take a full history, and the claim still comes back. Sometimes the code was wrong for the license. Sometimes the plan already paid a 90791 psychiatric diagnostic evaluation for this episode of care.

CPT 90791 is the psychiatric diagnostic evaluation without medical services. It is the intake code for that work. It is not a label you can put on every first appointment.

This is who can bill it, what the note has to show, and when a repeat is actually allowed.

What a 90791 Psychiatric Diagnostic Evaluation Includes

CPT describes a psychiatric diagnostic evaluation as an integrated biopsychosocial assessment. It includes history, mental status, and recommendations. It may also include contact with family or other sources, and review of diagnostic studies.^[1]

That is the work. The code is not built on a minute count. A 60-minute intake and a 90-minute intake can both be CPT 90791 if you did a diagnostic evaluation and you did not add medical services.

Medical services are the line. Prescribing, a medication assessment, and exam elements belong on 90792. A long clinical interview does not cross that line by itself.

Reviewing diagnostic studies can sit inside 90791. The 2026 definition allows it. Ordering a lab is not, on its own, a reason to bill 90792.

A solo LCSW in St. Paul uses 90791 for a new adult client: history, a mental status exam, a diagnosis, and a recommendation for weekly therapy. Session four is psychotherapy. The intake code stays on day one.

Who Should Bill 90791, and Who Should Bill 90792

Psychologists, clinical social workers, counselors, and marriage and family therapists bill 90791. The medical services in 90792 are outside their scope. A thorough evaluation does not change the license.

A psychiatrist or psychiatric nurse practitioner can bill 90791 when the visit truly had no medical services. If they reviewed medications, completed exam elements, or wrote a prescription, 90791 vs 90792 is not a close call. The visit is 90792.

The denial we see in group practices is a setup problem. Someone copies a prescriber's billing profile onto a new therapist. Every intake then goes out as 90792, and every one of them denies.

A Minneapolis group with four therapists and one psychiatric NP can share an intake packet. They cannot share one default code. Contracting and credentialing only helps if the claim still matches the person who did the work.

Your coordinator should know the roster. When a new clinician starts, the code list has to match the license before the first intake is billed.

What the Note Needs Before You Submit CPT 90791

Payers audit this code because the clock will not save it. The note has to show a diagnostic evaluation, not a therapy check-in.

Write the presenting problem in the client's words. Add the history you actually used: psychiatric, medical, family, and social, as far as it matters. Then record a mental status exam with observations. "Affect appropriate" is a conclusion. It is not an exam.

Add a risk assessment when the client denies suicidal or homicidal ideation. Say that you asked. If risk is present, write what you did about it.

Close with a specific ICD-10 code and treatment recommendations: modality, frequency, and what you are treating. An unspecified code, when the note supports a specific one, invites a medical-necessity review.

A psychologist in Rochester used a 90834 template for intakes. It was thin for a diagnostic evaluation. Intakes need their own form.

90791 documentation requirements are a checklist you can finish before the claim goes out. History, exam, risk, diagnosis, plan. If one of those is missing, fix the note before you bill.

How Often You Can Repeat a Psychiatric Diagnostic Evaluation

Most payers treat this as once per episode of care. A second one needs a clinical reason you can point to in the chart.

Medicare contractor guidance allows another diagnostic evaluation after an extended break, which that guidance treats as about six months. It also allows a repeat after an inpatient psychiatric admission, or when mental status changes enough to need a new assessment. A second opinion or a real diagnostic clarification can qualify too.^[2]

Commercial policies are not copies of that guidance. BCBS of Oklahoma's 2025 psychiatry policy allows 90791 or 90792 once at the start of treatment, and again only after a break of at least six months.^[3]

Some Medicaid programs are stricter. Indiana allows one unit of 90791 or 90792 per member, per rendering provider, per rolling 12 months without prior authorization. A second unit can be paid when a physician or HSPP and another behavioral health practitioner each complete an evaluation. More than that needs authorization. That same program does not allow psychotherapy, including crisis, on the same day.^[4]

Do not treat Indiana's rule as the national rule. Do treat it as a reason to check the plan before you repeat the code.

An insurance change is not a new episode. A clinic in Duluth rebilled 90791 because a client moved off Medical Assistance and onto a commercial plan. The clinical story had not changed. The claim denied, and it should have.

A second appointment is not a new episode either. Practices split one intake across two sessions and bill 90791 both times. That question comes up often, including in this therapist thread on two 90791s. The second hour is still the same evaluation. Some commercial plans pay more than one unit in a year. Others follow a once-per-episode rule, like the Medicare contractor guidance and the BCBS of Oklahoma policy above.^[2]^[3] Check before you bill that second hour as another 90791. If the plan denies it, the second date is psychotherapy, as long as the minutes and the note support a therapy code.

Do not report 90791 with crisis codes 90839 or 90840.^[3] Same-day psychotherapy is payer-specific. Some plans allow it with another clinician. Some deny it from the same provider. Verify that before you stack the codes.

Telehealth Intakes and the Add-On That Sometimes Belongs

A video intake is still a 90791 psychiatric diagnostic evaluation. The place of service has to match where the client sat.

Use POS 10 when the client is at home. Use POS 02 when they are somewhere else. POS 11 is an office visit, in the room. On a professional claim, the place of service is how you show the visit was telehealth. Do not add modifier 95. That modifier belongs on certain institutional claims, and it can disrupt a CMS-1500.

Interactive complexity, 90785, can be added when the session meets the criteria and you document the factor. The factors include communication that is hard to manage, a caregiver whose behavior gets in the way of the plan, a sentinel event that requires a mandated report, or an interpreter or device you needed to deliver the care.^[2] A difficult hour is not enough.

An Illinois group had sound intake notes and a bad default. Every video intake left the office as POS 11. The clinical work was fine. The claims were not.

Repeated intake denials are usually one of three things: the license, the timing, or the place of service. Denial tracking shows which one it is. A weak clean claim rate on new clients is often this code.

Which Intake Code to Use

When the question is the type of visit, use this before you open the fee schedule.

Visit	Code
Non-prescriber intake, with no medical services	90791
Prescriber intake that includes a medication decision, an exam element, or another medical service	90792
Second session of the same intake	Another 90791 or 90792 only if that payer's repeat rule allows it. Otherwise, psychotherapy.
The visit after the evaluation is done	Psychotherapy. A prescriber's medication follow-up is an E/M code. Add 90833, 90836, or 90838 only when the therapy time is separate.

Final Thoughts

A 90791 psychiatric diagnostic evaluation is the right code when you complete a diagnostic assessment and you do not provide medical services. The note has to prove that work. The license has to match. A repeat has to fit the payer's rule, not the calendar on the insurance card.

That is manageable when someone who knows your roster looks at the pattern with you. BreezyBilling assigns a coordinator who can see a copied billing profile, a too-soon repeat, or a telehealth place of service before it becomes a month of rework.

If you want a second set of eyes on how your intakes are coded, BreezyBilling is here to help.

Sources

Psychiatric Diagnostic Evaluation — CodingIntel, citing CPT Professional Edition 2026, American Medical Association
Local Coverage Billing and Coding Guidelines, Psychiatric Diagnostic Interview Examination — CMS Medicare Coverage Database, LCD L34616 attachment
Psychiatry/Psychotherapy Services, CPCP051 — Blue Cross and Blue Shield of Oklahoma, 2025
Psychiatric Diagnostic Evaluation Frequency — Anthem Indiana Medicaid, citing 405 IAC 5-20-8

How to Bill a 90791 Psychiatric Diagnostic Evaluation