Therapist’s Essential Guide to CPT Code 90791: Mastering the Intake Session
6 days ago
5 min read
If you are a therapist, you know that the first session with a client is arguably the most important. It is where rapport is built, stories are heard, and the roadmap for recovery is drawn. But in the background of that clinical connection, there is the administrative reality: getting paid for your time.
Navigating insurance billing can feel like learning a second language, but it doesn't have to be a headache. At the heart of your intake process lies CPT Code 90791. This isn't just a string of numbers; it is the foundation of your treatment planning and the key to a healthy revenue cycle for your practice.
Whether you are a psychologist, LCSW, or counselor, let’s break down exactly how to use the 90791 CPT code effectively, compliantly, and with confidence.
What Exactly Is CPT Code 90791?
In plain English, CPT Code 90791 is the billing code used for a psychiatric diagnostic evaluation without medical services.
Think of this as your "deep dive" session. It is distinct from a standard therapy hour (like 90837) because the focus isn't necessarily on doing therapy yet; it is about gathering information. When you bill the 90791 cpt code, you are telling the insurance company, "I am assessing this client’s history, mental status, and current needs to figure out how to help them."
What Does a 90791 Session Look Like?
When you sit down for a session billed under CPT Code 90791, you aren’t checking blood pressure or writing prescriptions. Instead, you are conducting a bio-psychosocial assessment that typically includes:
Building Rapport: Establishing trust so the client feels safe sharing.
History Taking: Reviewing family, medical, social, and psychiatric history.
Mental Status Exam (MSE): Observing mood, affect, cognition, and behavior.
Risk Assessment: Screening for safety issues, substance use, or trauma.
Diagnosis: determining a preliminary diagnosis based on DSM-5 or ICD-10 criteria.
Treatment Planning: Deciding on the frequency of sessions and therapeutic goals.
Who Is Allowed to Use the 90791 CPT Code?
One of the most common questions we hear is about eligibility. The 90791 cpt code was designed specifically for licensed mental health professionals who do not have prescribing privileges.
You are in the right place to use this code if you are a:
Licensed Clinical Social Worker (LCSW)
Licensed Professional Counselor (LPC) or Mental Health Counselor (LMHC)
Licensed Marriage and Family Therapist (LMFT)
Psychologist (PhD or PsyD)
If you are a medical provider (like a psychiatrist or nurse practitioner) who manages medications, you would generally skip CPT Code 90791 and use CPT 90792 instead.
90791 vs. 90792: What’s the Difference?
It is easy to get these mixed up, but the distinction is actually quite simple. It comes down to medical services.
CPT Code 90791: Used by non-medical therapists. The assessment is purely psychological and behavioral.
CPT Code 90792: Used by medical providers (MDs, DOs, NPs). This assessment includes medical components, such as physical exams, prescription management, and ordering labs.
If you do not prescribe medication, the 90791 CPT code is your go-to for intakes.
Documentation: How to Bulletproof Your Notes
You want to focus on your client, not your paperwork. However, passing an audit requires specific documentation. When you bill CPT Code 90791, your progress note needs to be more robust than a standard session note.
To ensure your 90791 CPT code claim is accepted, your note should clearly illustrate the "Golden Thread" of medical necessity. Here is a checklist of what to include:
Chief Complaint: Why is the client here in their own words?
History: A thorough review of their medical, family, and social background.
Current Symptoms: What are they struggling with right now?
Mental Status Exam (MSE): A formal description of their presentation (e.g., "Client appears anxious, affect is flat, thought process is linear").
Diagnosis: The specific ICD-10 code (e.g., F41.1 for Generalized Anxiety Disorder).
The Plan: What are you going to do? (e.g., "Recommend weekly CBT sessions for 12 weeks").
Logistics: Date, actual start/stop times, and location (office or telehealth).
Pro-Tip: Don't just clone your notes. The 90791 cpt code is a high-value code, and insurance auditors expect to see a unique, comprehensive evaluation for that specific date of service.
Timing and Frequency: When Can You Bill It?
How long should the session be?
While CPT Code 90791 does not have a strict time floor like therapy codes, the industry standard is between 45 to 90 minutes. It is virtually impossible to conduct a comprehensive, full biopsychosocial assessment in less than 45 minutes.
Can I use it more than once?
Generally, the 90791 cpt code is billed once per "episode of care." This usually means the very first visit. However, if a client disappears for six months and returns, or experiences a traumatic event that drastically changes their clinical presentation (like a stroke or a new addiction issue), you can bill CPT Code 90791 again to cover the re-evaluation.
Medical Necessity and ICD-10 Codes
To get paid for CPT Code 90791, you must link it to a diagnosis that justifies the service. This is where ICD-10 codes come in. You cannot simply bill the code; you must explain why the evaluation was needed.
Common diagnosis codes paired with the 90791 CPT code include:
F33.1: Major Depressive Disorder, Recurrent, Moderate
F41.1: Generalized Anxiety Disorder
F43.10: PTSD, Unspecified
F90.2: ADHD, Combined Presentation
Using the correct diagnosis ensures that the payer understands the medical necessity behind the 90791 CPT code.
Modifiers and Telehealth
The world of therapy has changed, and many of us are working remotely. Fortunately, CPT Code 90791 is valid for telehealth.
Telehealth: When billing the 90791 CPT code for a video session, you will likely need to add the 95 or GT modifier (depending on the specific insurance payer) to the claim form.
Interactive Complexity: If you are assessing a child and spend a significant amount of time managing high-conflict family dynamics or using play equipment to communicate, you may be able to add the 90785 modifier alongside CPT Code 90791.
Common FAQs About the 90791 CPT Code
1. Can I bill a therapy session (like 90837) on the same day as an intake? Usually, no. Most payers view CPT Code 90791 as an all-encompassing service for that day. It is best to do the evaluation on day one and start formal therapy on day two.
2. Does Medicare cover the 90791 CPT code? Yes! Medicare covers this code when it is medically necessary and performed by an eligible provider. Just ensure your documentation supports the time and complexity.
3. What if I am a psychiatrist, but I don't prescribe meds during the intake? Even if you don't write a script, if you have the capacity to perform medical services and are an MD/DO, payers often prefer you use 90792. However, some strictly define CPT Code 90791 as "no medical services provided," so check your local jurisdiction.
4. How often can I bill the 90791 CPT code? Typically, once per year or per episode of illness. If you are billing it every month for the same client, you will almost certainly trigger an audit.
Final Thoughts: More Than Just a Code
Mastering CPT Code 90791 is about more than just keeping the lights on in your practice. It is about honoring the complexity of your client's story. A well-documented intake sets the stage for effective treatment and protects your license.
By understanding the nuances of the 90791 CPT code, you free yourself from administrative anxiety. You can stop worrying about the billing department and start focusing entirely on the person sitting across from you, listening to them, understanding them, and helping them heal.