CPT and diagnosis codes

Psychiatric diagnostic evaluation is an integrated biopsychosocial assessment, including history, mental status and recommendations. The evaluation may include communication with family or other sources and review and ordering of diagnostic studies. Does not include psychotherapy services.

This code can be used by clinical psychologists, licensed professional counselors, licensed marriage and family therapists, and licensed clinical social workers, in addition to psychiatrists.

Each session billed with code 90791 must include the following (or have the following characteristics):

• Elicitation of a complete medical and psychiatric history
• Mental status examination
• Evaluation of the client’s ability and capacity to respond to treatment
• Initial plan of treatment
• The assessment must last a minimum of 16 minutes in order to receive reimbursement.

Medical Record Documentation for code 90791 must include the following:

• Exact time record
• Modalities and frequency
• Clinical notes that summarize:
  • Diagnosis
  • Symptoms
  • Functional status
  • Focused mental status examination
  • Treatment plan, prognosis, and progress
  • Name, signature*, and credentials of the person providing the service (*use /s/ to indicate Signature on Headway)

For clearer documentation direction, see our article on Progress Notes. 

You do not report 90791 more than once per day, nor do you report 90791 with E/M (Evaluation and management codes) services on the same day. In addition, psychotherapy services, including for crisis, may not be reported on the same day as 90791. Use 90785 in conjunction with 90791 when the diagnostic evaluation includes interactive complexity services.

Psychiatric diagnostic evaluation with medical services is an integrated biopsychosocial and medical assessment, including history, mental status, other physical examination elements as indicated, and recommendations. The evaluation may include communication with family or other sources, prescription of medications, and review and ordering of laboratory or other diagnostic studies.

This code can only be used by licensed medical providers, such as psychiatrists.

Each session billed with code 90792 must include the following (or have the following characteristics):

• Elicitation of a complete medical and psychiatric history
• Mental status examination
• Evaluation of the client’s ability and capacity to respond to treatment
• Initial plan of treatment
• The assessment must last a minimum of 16 minutes in order to receive reimbursement.

Medical Record Documentation for 90792 must include the following:

• Exact time record
• Modalities and frequency
• Clinical notes that summarize:
  • Presenting problem
  • History of present illness
  • Review of systems
  • Diagnosis
  • Symptoms
  • Functional status
  • Focused mental status examination
  • Treatment plan, prognosis, and progress
  • Name, signature*, and credentials of the person providing the service (*use /s/ to indicate Signature on Headway)

You do not report 90792 more than once per day, nor do you report 90792 with E/M services on the same day. In addition, psychotherapy services, including for crisis, may not be reported on the same day as 90792. Use 90785 in conjunction with 90792 when the diagnostic evaluation includes interactive complexity services.

The CPT® guidelines for interactive complexity give some common factors that necessitate the addition of 90785:

“Common factors include more difficult communication with discordant or emotional family members and engagement of young and verbally undeveloped or impaired clients.”

Clients that present interactive complexity typically have other individuals involved in their psychiatric care.

“These factors (presenting interactive complexity) are typically present with clients who:

• Have other individuals legally responsible for their care, such as minors or adults with guardians, or
• Request others to be involved in their care during the visit, such as adults accompanied by one or more participating family members or interpreter or language translator.
• Require the involvement of other third parties, such as child welfare agencies, parole or probation officers, or schools.”

According to the CPT® guidelines, one of the following must exist to report the interactive complexity add-on code:

• Maladaptive communication that complicates care
• Emotional or behavioral conditions attributed to the caregiver that interfere with implementation of care
• A sentinel event (abuse or neglect), mandatorily reported, is suspected or disclosed
• Use of play equipment, physical devices, an interpreter, or translator are necessary for the client to communicate their symptoms and overcome interactive barriers

The American Academy of Child and Adolescent Psychiatry provides the following guidance on when reporting interactive complexity is NOT appropriate:

• Multiple participants in the visit with straightforward communication
• Client attends visit individually with no sentinel event or language barriers
• Treatment plan explained during the visit and understood without significant interference by caretaker emotions or behaviors

Psychotherapy for Crisis Psychotherapy provided to a client in a crisis state is reported with codes 90839 and 90840 and cannot be reported in addition to the psychotherapy codes 90832 – 90838.

Psychotherapy for crisis is an urgent assessment and history of a crisis state, a mental status exam, and a disposition. The treatment includes psychotherapy, mobilization of resources to defuse the crisis and restore safety, and implementation of psychotherapeutic interventions to minimize the potential for psychological trauma. The presenting problem is typically life threatening or complex and requires immediate attention to a client in high distress.

Codes 90839 and 90840 are used to report the total duration of time face-to-face with the client and/or family spent by the physician or other qualified health care professional providing psychotherapy for crisis, even if the time spent on that day is not continuous. For any given period of time spent providing psychotherapy for crisis state, the physician or other qualified health care professional must devote their full attention to the client and, therefore, cannot provide services to any other client during the same time period. The client must be present for all or some of the service.

Psychotherapy for crisis of less than 30 minutes total duration on a given date should be reported with 90832 or 90833 (when provided with E/M services). Code 90839 is used to report the first 30 – 74 minutes of psychotherapy for crisis on a given date.

It should be used only once per date even if the time spent by the physician or other health care professional is not continuous on that date. Code 90840 is used to report additional block(s) of time, up to 30 minutes each beyond the first 74 minutes.

Please always follow the below guidelines:

• Do not report CPT codes 90839 or 90840 with 90791 or 90792.
• Do not report CPT codes 90839 or 90840 with 90832 – 90838.
• Do not report CPT codes 90839 or 90840 with 90785 – 90899.

We offer common E/M codes at Headway to be used by prescribers in visits:

• 99203, 99204, and 99205—to be used with new clients.
• 99213, 99214, and 99215—to be used with established clients.

New Clients

A new client is one who has not received any professional services from the physician / qualified health care professional or another physician / qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past 3 years. When advanced practice nurses and physician assistants are working with physicians, they are considered as working in the exact same specialty and exact same subspecialties as the physician.

Established Clients

An established client is one who has received professional services from the physician / qualified health care professional or another physician / qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past 3 years.

Guidelines for Office E/M Services

History and/or Examination

Office or other outpatient services include a medically appropriate history and/or physical examination, when performed. The nature and extent of the history and/or physical examination are determined by the treating physician or other qualified health care professional reporting the service. The extent of history and physical examination is not an element in selection of the level of office or other outpatient codes.

Number and Complexity of Problems Addressed at the Encounter

One element used on selecting the level of office or other outpatient services is the number and complexity of problems that are addressed at an encounter. Multiple new or established conditions may be addressed at the same time and may affect MDM (Medical decision making). Symptoms may cluster around a specific diagnosis and each symptom is not necessarily a unique component.

Co-morbidities / underlying diseases, in and of themselves, are not considered in selecting a level of E/M services unless they are addressed, and their presence increases the amount and/or complexity of data to be reviewed and analyzed or the risk of complications and/or morbidity or mortality of client management.

The final diagnosis for a condition does not, in and of itself, determine the complexity or risk, as extensive evaluation may be required to reach the conclusion that the signs or symptoms do not represent a highly morbid condition. Multiple problems of a lower severity may, in the aggregate, create higher risk due to interaction.

Definitions for the Elements of MDM

Problem

A problem is a disease, condition, illness, injury, symptom, sign, finding, complaint, or other matter addressed at the encounter, with or without a diagnosis being established at the time of the encounter.

Problem Addressed

A problem is addressed or managed when it is evaluated or treated at the encounter by the physician or other qualified health care professional reporting the service. This includes consideration of further testing or treatment that may not be elected by virtue of risk/benefit analysis or client/parent/guardian/surrogate choice. Notation in the client’s medical record that another professional is managing the problem without additional assessment or care coordination documented does not qualify as being addressed or managed by the physician or other qualified health care professional reporting the service. Referral without evaluation (by history, examination, or diagnostic study[ies]) or consideration of treatment does not qualify as being addressed or managed by the physician or other qualified health care professional reporting the service.

Instructions for Selecting a Level of Office or Other Outpatient E/M Services

Select the appropriate level of E/M services based on the following:

• The level of the MDM as defined for each service, or
• The total time for E/M services performed on the date of the encounter.

Office / Outpatient Evaluation and Management (E/M) Tables

Guidelines for Office or Other Outpatient E/M Services

History and/or Examination

Office or other outpatient services include a medically appropriate history and/or physical examination, when performed. The nature and extent of the history and/or physical examination are determined by the treating physician or other qualified health care professional reporting the service. The extent of history and physical examination is not an element in selection of the level of office or other outpatient codes.

Number and Complexity of Problems Addressed at the Encounter

One element used on selecting the level of office or other outpatient services is the number and complexity of problems that are addressed at an encounter. Multiple new or established conditions may be addressed at the same time and may affect MDM. Symptoms may cluster around a specific diagnosis and each symptom is not necessarily a unique component.

Co-morbidities / underlying diseases, in and of themselves, are not considered in selecting a level of E/M services unless they are addressed, and their presence increases the amount and/or complexity of data to be reviewed and analyzed or the risk of complications and/or morbidity or mortality of client management.

The final diagnosis for a condition does not, in and of itself, determine the complexity or risk, as extensive evaluation may be required to reach the conclusion that the signs or symptoms do not represent a highly morbid condition. Multiple problems of a lower severity may, in the aggregate, create higher risk due to interaction.

Definitions for the Elements of MDM

Problem

A problem is a disease, condition, illness, injury, symptom, sign, finding, complaint, or other matter addressed at the encounter, with or without a diagnosis being established at the time of the encounter.

Problem Addressed

A problem is addressed or managed when it is evaluated or treated at the encounter by the physician or other qualified health care professional reporting the service. This includes consideration of further testing or treatment that may not be elected by virtue of risk/benefit analysis or client/parent/guardian/surrogate choice. Notation in the client’s medical record that another professional is managing the problem without additional assessment or care coordination documented does not qualify as being addressed or managed by the physician or other qualified health care professional reporting the service. Referral without evaluation (by history, examination, or diagnostic study[ies]) or consideration of treatment does not qualify as being addressed or managed by the physician or other qualified health care professional reporting the service.

Instructions for Selecting a Level of Office or Other Outpatient E/M Services

Select the appropriate level of E/M services based on the following:

• The level of the MDM as defined for each service, or
• The total time for E/M services performed on the date of the encounter.

MDM includes establishing diagnoses, assessing the status of a condition, and/or selecting a management option. MDM in the office or other outpatient setting is defined by three elements:

• The number and complexity of problem(s) that are addressed during the encounter.
• The amount AND/OR complexity of data to be reviewed and analyzed. Data includes medical records, tests, and/or other information that must be obtained, ordered, reviewed, and analyzed for the encounter. This includes information obtained from multiple sources or interprofessional communications that are not reported separately and interpretation of tests that are not reported separately. Ordering a test is included in the category of test result(s) and the review of the result is part of the encounter and not a subsequent encounter.

Data is divided into three categories:

1. Tests, documents, orders, or independent historian(s).
2. Independent interpretation of tests.
3. Discussion of management or test interpretation with external physician or other qualified health care professional or appropriate source.

The risk of complications and/or morbidity or mortality of client management decisions made at the visit, associated with the client’s problem(s), the diagnostic procedure(s), treatment(s). This includes the possible management options selected and those considered but not selected, after shared MDM with client and/or family.

MDM is divided into four levels: straightforward, low, moderate, and high.

To qualify for a particular level of MDM, two of the three elements for that level must be met or exceeded. See MDM table for additional information.

Office / Outpatient Evaluation and Management (E/M) - MDM Table