In simple words: The doctor performs a thorough mental health check-up including talking about the patient's history, current situation, and physical health. The doctor might also order tests or prescribe medicine and create a treatment plan. This evaluation is done by a doctor who can prescribe medicine, unlike a simple mental health assessment.

This CPT code represents a psychiatric diagnostic evaluation that integrates biopsychosocial and medical assessments.The evaluation encompasses a thorough review of the patient's history (past, family, social), a comprehensive mental status examination, and any necessary elements of a physical examination.The process culminates in recommendations for treatment.Additional components may include communication with family or other sources, prescription of medications, and ordering or reviewing laboratory or other diagnostic studies.The assessment can be for new patients or reevaluations.

Example 1: A new patient presents with symptoms of depression and anxiety. The psychiatrist performs a complete psychiatric diagnostic evaluation, including a medical history, mental status examination, and a brief physical exam.Blood work is ordered to rule out any underlying medical conditions. The psychiatrist then creates a comprehensive treatment plan which includes medication and therapy referrals., An existing patient returns for a follow-up evaluation of their treatment for bipolar disorder. The psychiatrist conducts a comprehensive assessment, including reviewing the patient's medication response, adjusting medication dosages as needed, and discussing the patient’s progress in therapy. The psychiatrist orders lab tests to monitor the efficacy of medication and overall wellness. , A patient is brought in by family after experiencing a significant change in behavior, including suicidal ideation.A full psychiatric diagnostic evaluation is conducted. A physical exam is performed to rule out physical causes.A hospital stay is recommended and initiated for close observation and further evaluation of the patient's condition.

Comprehensive medical and psychiatric history (including past, family, and social history); detailed mental status examination; results of any ordered laboratory or diagnostic tests; physical examination findings (as applicable); diagnosis; treatment plan; notes on any communication with family or other informants.

** This code is primarily used by clinicians with prescriptive authority, such as psychiatrists and psychiatric nurse practitioners.Reimbursement rates will vary depending on payer, location, and provider type.