In simple words: This code covers a thorough mental health checkup by a psychiatrist or qualified mental health professional.The doctor will talk to you about your mental health history, current situation, and family history,perform a mental health exam, and make recommendations for your treatment. They may also talk to your family or other people close to you and order tests to help with the diagnosis.

CPT code 90791 describes a psychiatric diagnostic evaluation. This is a comprehensive biopsychosocial assessment involving a detailed history of the patient's present and past behavioral concerns, family history, medical history, and social history. The evaluation also includes a mental status examination,recommendations for further treatment or management, and may involve communication with family members or other informants.It may also include the review and ordering of laboratory or other diagnostic studies. This code is used for initial evaluations or re-evaluations of patients and should be reported only once per day, regardless of time spent with the patient.

Example 1: A new patient presents with symptoms of depression and anxiety. The psychiatrist performs a 90791 evaluation, including a detailed history, mental status exam, and diagnostic interviews, leading to a diagnosis of major depressive disorder with generalized anxiety disorder., A patient with a pre-existing diagnosis of schizophrenia is experiencing worsening symptoms. The psychiatrist performs a 90791 reassessment to evaluate the patient's current mental status, medication effectiveness, and overall response to treatment, potentially adjusting the treatment plan accordingly., A child is referred for behavioral issues at school. The psychiatrist conducts a 90791 evaluation, which includes interviews with the child, parents, and school staff, leading to a diagnosis of attention-deficit/hyperactivity disorder (ADHD).

Comprehensive documentation should include a detailed history (presenting complaint, history of present illness, past psychiatric history, past medical history, family history, social history, medication history), mental status examination, results of any diagnostic tests administered, and the final diagnosis and treatment plan.Documentation should clearly support medical necessity.

** This code should only be reported once per day, even if multiple sessions were held on the same day. The use of this code should be carefully considered in conjunction with E/M codes, to avoid unbundling.Always consult the most recent CPT manual and payer guidelines for the most accurate and updated information on coding and billing rules.