There are many different CPT codes in health billings, and it can be difficult to remember them all.
Among these, one of the most frequently used in behavioral health is 90791 CPT code. This code is very important in the early phases of treatment since it covers thorough evaluations that give mental health providers a comprehensive picture of a patient’s state.
90791 CPT Code Explained
The 90791 CPT code is commonly used by licensed behavioral health providers for an integrated biopsychosocial assessment, which includes the patient’s history, mental status, and recommendations.
It is typically used for diagnostic evaluations related to new behavioral health concerns or illnesses, often billed for the initial intake appointment that each new patient undergoes at the beginning of treatment.
After the initial assessment with CPT code 90791, follow-up appointments are billed using codes 90834 or 90837, depending on the duration of the session.
This code can be used by various mental health professionals, including Licensed Clinical Social Workers (LCSWs), Licensed Mental Health Counselors (LMHCs), Licensed Professional Counselors (LPCs), Licensed Marriage and Family Therapists (LMFTs), clinical psychologists, and psychiatrists.
90791 CPT Code Add-on Codes
90791 CPT code can be used with add-on CPT codes for time-based billing when the diagnostic interview exceeds 90 minutes.
The following add-on CPT codes can be applied for longer sessions:
- +99354: Represents an additional 30-45 minutes of time. Use 90791 + 99354 if the session lasts between 90 and 120 minutes (1.5 to 2 hours).
- +99355: Represents an additional 45 minutes. Use 90791 + 99354 + 99355 if the session lasts between 2-3 hours.
What are the 90791 CPT Code Time Requirements?
90791 CPT code has specific time requirements set by the Centers for Medicare Services (CMS). The session must be a minimum of 16 minutes and should not exceed 90 minutes before additional CPT codes are required.
Typically, a standard session is around 60 minutes. For sessions exceeding 90 minutes, Medical Claims Billing can assist you in adding the appropriate add-on code to ensure proper billing.
Can 90791 CPT Code be Billed Multiple Times for One Client?
The frequency with which the 90791 CPT code can be billed for an individual client varies based on their insurance plan.
For public health institutions, most coverage plans permit billing CPT code 90791 only once per client per provider in any given year. Some private insurance plans may allow this code to be billed as frequently as once every six months.
If you are unsure about the specifics of a client’s coverage, it’s best to contact their insurance provider for verification.
Does 90791 CPT Code Require Authorization?
90791 CPT code is typically used for a routine outpatient mental health evaluation, which usually doesn’t require prior authorization. However, there are exceptions based on the patient’s health plan and specific insurance provider policies.
Some insurance providers may only grant a single authorization for CPT code 90791. After that, other codes like 90834 or 90837 may be used for Employee Assistance Program (EAP) sessions.
It’s important to verify a new patient’s coverage during the scheduling process and ask their provider specifically about CPT code 90791.
You should check the client’s insurance plan for eligibility and benefits to see if authorization is required. Many mental health billing services offer this verification for free as part of their service.
Does CPT Code 90791 Pay More Than a Standard Outpatient Session?
Yes, 90791 CPT code almost always pays more per outpatient session compared to 90834 or 90837. The exact payment varies depending on the credentialing of the mental health provider and the patient’s insurance plan.
In most cases, 90791 is reimbursed at +35-75% of the typical 90834 rate or +10-50% of the 90837 rate.
Average Reimbursement Rate for 90791 CPT Code
According to the Centers for Medicare and Medicaid Services, the average reimbursement rate for the 90791 CPT code is approximately $145.00, with sessions lasting between 20 to 90 minutes.
In comparison, CPT code 90792 has an average reimbursement rate of around $160.00 for a similar session performed by a psychiatrist.
While these reimbursement rates for CPT code 90791 are established by Medicare and represent national averages, they can vary based on factors such as geographic location, demographic demand, and the provider’s specialty. Typically, providers who are not Ph.D. or MD holders may receive lower reimbursement rates.
What Are the Requirements for Utilizing the 90791 CPT Code?
There are certain requirements that must be met to utilize the 90791 CPT code as part of a comprehensive initial mental health evaluation for a new patient seeking mental health services.
These requirements include:
- Conducting a thorough mental status examination
- Evaluating the patient’s ability and capacity to respond to treatment
- Collecting and documenting a complete medical and psychiatric history
- Formulating recommendations within the initial treatment plan
- Ensuring the evaluation occurs during a face-to-face meeting between the new patient and the provider
Minimize Billing Errors With MCB
Mistakes in the application of CPT codes can lead to significant delays in reimbursement and an increased risk of claim denials, especially if 90791 CPT code is billed more frequently than allowed by the patient’s insurance provider.
If you are a solo practitioner or manage a small practice with limited administrative staff, you may find yourself juggling multiple responsibilities.
When you entrust your medical billing requirements to a third-party company such as Medical Claims Billing, you can count on skilled professionals to guarantee precise coding.
