90791 CPT Code: Intake Evaluation Billing Rules and Limits

CPT code 90791 is the code for a psychiatric diagnostic evaluation without medical services, which is the standard intake assessment most therapists, counselors, social workers and psychologists bill at a client’s first visit. It is not a timed code and is usually billed once at the start of treatment. Prescribers who include medical services in the evaluation use 90792 instead.

Below you will find what 90791 includes, how it differs from 90792, how often it can be billed, same-day restrictions, telehealth notes and an example superbill line.

What is the 90791 CPT code?

In plain words, 90791 describes an initial diagnostic assessment by a mental health clinician that does not include medical services. A typical 90791 visit gathers enough information to establish a diagnosis and a treatment plan. It commonly includes:

• The reason the client is seeking care and the history of the current problem
• Psychiatric, medical, substance use, family and social history
• A mental status exam
• Risk assessment
• A diagnosis (or provisional diagnosis) and treatment recommendations
• Communication with family members or other sources, and review of records, when relevant

The visit may involve the client alone, the client with a family member, or, for children, a parent or guardian as an informant.

Who can bill 90791?

90791 can be billed by licensed clinicians whose scope of practice includes diagnosis, such as psychologists, clinical social workers, professional counselors, marriage and family therapists, psychiatric nurse practitioners and psychiatrists. As with other codes, each payer decides which license types it will credential and reimburse, and state law sets scope of practice.

90791 vs 90792: what’s the difference?

The difference is whether medical services are part of the evaluation.

If you are a non-prescribing therapist, you will almost always bill 90791. If you are a psychiatrist or psychiatric NP and you evaluate medications, order labs or perform physical exam elements during the intake, 90792 is the closer fit. The psychiatrist superbill template includes both codes.

Is there a time requirement for 90791?

No. Unlike the psychotherapy codes (90832, 90834, 90837), 90791 is not defined by time. You report it once for the evaluation whether it takes 45 minutes or 90.

That said, document your start and stop times anyway. Some payers expect to see time in the note, and it helps show that a thorough evaluation took place. If the evaluation is unusually short, make sure the note still covers the core components listed above.

Some payers recognize a prolonged-service add-on when a diagnostic evaluation runs much longer than usual. Which code applies and whether it is covered depends on the payer and the current CPT code set, so confirm before billing one.

What should a 90791 note include?

Because 90791 is not timed, payers judge it by content. A complete intake note usually documents:

1. Who was present and who provided information (client, parent, partner, prior records).
2. Presenting problem and history, including onset, duration and severity of symptoms.
3. Relevant background: psychiatric, medical, substance use, family and social history.
4. Mental status exam findings.
5. Risk assessment, including safety planning when indicated.
6. Diagnosis with ICD-10 codes, or the symptoms supporting a provisional assessment.
7. Recommendations and a treatment plan, including the recommended frequency of follow-up sessions.

Recording start and stop times is optional under CPT for this code, but it costs nothing and answers a common reviewer question.

Can 90791 be billed more than once?

This is one of the most common 90791 questions, and the honest answer is that it depends on the situation and the payer.

What CPT allows. CPT guidance permits reporting 90791 more than once for the same patient when separate diagnostic evaluations are done on different days, for example meeting with the patient on one day and with a parent or other informant on another. This comes up often with child and adolescent intakes.

What payers allow. Many payers set their own frequency limits, such as once per episode of care, once per provider, or once within a set time period. Additional evaluations may be covered with documented medical necessity, for example:

• A significant change in the client’s condition
• A new episode of care after a long gap in treatment
• A transfer to a new clinician or practice
• A required re-evaluation for a level-of-care change

Because these rules vary widely, check the plan’s behavioral health policy or call the provider line before billing a second 90791 within a short window.

Can 90791 be billed on the same day as psychotherapy?

Generally, no. Most payers do not allow 90791 and a psychotherapy code (90832, 90834 or 90837) for the same patient, by the same provider, on the same date. Payers also typically do not allow 90791 with an E/M service on the same day by the same provider.

What this means in practice:

• Intake session: bill 90791 only, even if part of the visit felt like therapy.
• Second session onward: bill the psychotherapy code that matches the documented time. See our guides to CPT code 90834 and CPT code 90837.

Add-on that can apply: 90785 (interactive complexity) can be reported with 90791 when a qualifying factor made communication during the evaluation more difficult, such as a caregiver whose behavior interferes with the assessment or the need for play equipment with a young child. Interpretation alone does not qualify.

Psychological testing is separate. Testing and test interpretation have their own code families and are not part of 90791.

Can 90791 be billed for telehealth?

Many payers cover 90791 by real-time video, and intake evaluations are now routinely done by telehealth. When you bill it:

• Use the place of service your payer requires. Many use POS 10 when the client is at home and POS 02 when the client is somewhere else, while some commercial payers still want the in-person POS (often 11) plus a modifier.
• Add a modifier if required. Modifier 95 is common for audio-video; some payers use GT; some use 93 for audio-only.
• Document the client’s location, the modality and consent.

Telehealth modifier and POS rules have changed several times in recent years and differ between Medicare, Medicaid and commercial plans. Check current payer and CMS guidance before submitting.

How do you put 90791 on a superbill?

For out-of-network clients, the intake is usually the first line on their first superbill. Example (fictional data):

Diagnosis:

• A — F43.10 (post-traumatic stress disorder, unspecified)

Provider block: practice name, provider name and credentials, address, phone (for example (555) 010-0162), NPI (for example 1234567893), EIN (for example 12-3456789) and license number. Client block: name, date of birth, insurance carrier, member ID and group number.

What diagnosis should go on a 90791 line?

Use the diagnosis you established, or the most specific one supported by the evaluation. Under ICD-10-CM outpatient coding guidelines, you should not code a condition listed as “rule out” or “suspected”; instead, code to the highest degree of certainty for that visit, which may be the presenting symptoms. Insurers generally require a diagnosis on every line, so an intake superbill without one is likely to be rejected.

Should the intake fee be different?

Many practices charge a higher fee for 90791 than for a standard session because the evaluation and documentation take longer. Whatever you charge, list your full fee on the superbill and show amounts paid separately. If the client is self-pay or uninsured, you may also need to give them a Good Faith Estimate before the first visit.

Common 90791 billing problems

• Billing 90791 and a psychotherapy code on the same date. Pick 90791 for the intake visit.
• Billing 90791 again too soon without checking the payer’s frequency limit or documenting why a new evaluation was needed.
• Using 90792 without medical services documented, or using 90792 as a non-prescriber.
• No diagnosis or diagnosis pointer on the line.
• Telehealth POS or modifier that doesn’t match the payer’s current rules.
• Incomplete intake note that lacks a mental status exam, risk assessment or treatment recommendations.

Build your intake superbill now

The free superbill generator lets you add 90791 and follow-up sessions on one superbill, letters diagnoses A–L, checks your NPI and flags missing fields insurers usually require. Everything stays in your browser. Psychologists can start from the psychologist superbill template, which preloads 90791 and common psychotherapy codes.