The Initial assessment (CPT 90791) is the foundation of a patient’s treatment journey. A thorough, well-structured 90791 establishes a clinical roadmap by:
- Capturing an accurate diagnostic picture grounded in evidence-based assessment
- Identifying risk and patient safety treatment needs early
- Demonstrating medical necessity and meeting payer and regulatory requirements
- Providing clear, clinically meaningful documentation that informs treatment planning and supports continuity of care
Because of its critical role, Headway’s Clinical Quality team - composed of licensed therapists - periodically reviews 90791 documentation to ensure assessments meet industry wide standards for safe and effective care. The review utilizes a standardized 90791 rubric to support consistency across all providers.
The following sections outline the required elements that must be reflected in 90791 documentation, as well as how to meet those standards.
Clearly document the patient’s presenting problem and reason for seeking treatment. When possible, use the patient’s own words to best reflect their concerns and experiences.
Document whether the patient currently uses any substances. If so, include the type, amount, and frequency. If no use is reported, please document "none reported". Note that vague statements such as “client drinks socially” will not meet standard, as it does not identify what “socially” means (ie the amount and frequency). This applies to all substances, including nicotine and medical marijuana.
Document whether the patient has a history of trauma, including experiences such as abuse, neglect, or violence. If no history is reported, please document “none reported.”
Document whether the client has a history of any self-harm behaviors. If reported, be sure to document the method of harm, approximate time period or date of self harm behavior and whether medical attention was needed. If none, please document "none reported".
Document whether the client has a history of any harm to others. If reported, be sure to document the method of harm, approximate time period or date of the harming behavior and whether legal consequences resulted. If none, please document "none reported".
Specific assessment of current suicidal ideation and homicidal ideation must be clearly documented. Note that generalized risk assessment statements that do not explicitly address SI and HI will not meet standard (i.e “Client has no risk” without identifying what kind of risk). If there is no current SI or HI reported, state that clearly, for example "Client denies current SI and HI".
In the case suicidal or homicidal ideation IS present, there must be documentation of whether the client has a plan. If they do have a plan, then there must also be documentation of assessing for both means and intent.
In the case a client reports current or recent (within the past 30 days) suicidal or homicidal ideation with a plan, the documentation must clearly show the steps taken to reduce risk and enhance safety. This may include completing a safety plan, discussing removal of access to means, or escalating for emergency evaluation.
If any risk indicators are documented in the note—such as current violence, abuse or neglect, active psychosis, grave disability, or severe substance use with safety concerns—you must also document the actions taken to address or mitigate that risk. Examples include safety planning, providing crisis resources, making referrals, mandated reporting, or arranging emergency evaluation.
Ensure all billed diagnoses are supported by the specific DSM-5-TR criteria, including specific symptoms, onset/duration, frequency, and areas of functional impairment.
Include reference to use, or planned use, of an evidence based approach to treatment in future documentation.
When required elements are missing or only partially met, we provide proactive, constructive feedback directly in Sigmund to help providers strengthen their documentation moving forward. This process is designed to be collaborative and supportive as an effort to enhance clinical clarity and reduce risk - not to penalize providers.
Headway Academy educational offerings
In addition to the above 90791 rubric, the Clinical Team offers short, easy-to-digest courses to assist in quality care delivery. We put together a learning pathway that includes the following courses (click the links below to be redirected to each individual course):
- Golden Thread [5 minutes]
- Clinical Consultation and Intake for Mental Health Therapists [10 minutes]
- Clinical Short: Navigating Diagnosis Formulation [10 minutes]
- Risk Assessment and Safety Planning [10 minutes]
- Medical Necessity [10 minutes]
- Write compliant intake notes, treatment plans, and progress notes [15 mins]
Continuing education
Headway also offers free Continuing Education Units (CEUs) through our partners Violet and PESI. You can learn more about our offerings in our Help Center article: Using Violet, PESI, or the ERC for continuing education with Headway.