Introduction
Accurate medical coding is fundamental to behavioral health reimbursement, clinical documentation integrity, and regulatory compliance. Among the most frequently used codes in psychiatric and mental health settings is CPT 90792, the code for Psychiatric Diagnostic Evaluation With Medical Services. Providers who deliver diagnostic evaluations that include medical elements—such as reviewing labs, conducting physical exams, managing medications, or assessing medical comorbidities—must understand the correct use of 90792 to avoid denials and ensure clinical clarity.
This extended guide provides a deep exploration of CPT 90792, covering what the service includes, how it differs from CPT 90791, necessary documentation requirements, payer expectations, and frequently misunderstood billing scenarios. Whether you’re a psychiatrist, psychiatric nurse practitioner, or a billing professional supporting behavioral health, this article provides the detail needed for consistent and compliant use of CPT 90792.
What CPT 90792 Represents
CPT 90792 describes a comprehensive psychiatric diagnostic evaluation that includes medical services. This distinguishes it from 90791, which is used by non-medical clinicians or by situations where medical components are not performed.
The service typically includes:
1. A Thorough Psychiatric Assessment
This includes:
- History of present illness
- Review of symptoms
- Psychiatric, family, and social history
- Substance use and safety assessments
Psychiatrists are expected to document mental status examinations and patient interactions in detail.
2. Medical Evaluation Components
Since 90792 is a medical diagnostic code, the evaluation may include:
- A review of medical history
- Medication reconciliation
- Physical exam (if clinically warranted)
- Review of labs, imaging, or diagnostic tests
- Ordering or recommending new tests
These medical components justify billing 90792 instead of 90791.
3. Development of Initial Treatment Plan
Providers typically outline:
- Diagnostic impressions
- Medication recommendations
- Therapy recommendations
- Safety planning
- Follow-up frequency
The treatment plan demonstrates medical decision-making, which insurers often scrutinize.
90792 vs. 90791 – Understanding the Difference
Confusion between these two codes is common. The distinction matters because using the wrong code may cause denials or compliance issues.
90791 – Non-Medical Diagnostic Evaluation
Used by:
- Psychologists
- Licensed clinical social workers
- Counselors
- Therapists
This code does not include medical evaluations, prescribing authority, or physical examination.
90792 – Medical Diagnostic Evaluation
Used by:
- Psychiatrists
- Psychiatric NPs
- Physicians configuring treatment plans
- Any clinician with prescribing privileges
This code requires medical decision-making and medical assessment.
Key Reminder:
If any medical component is performed, even a medication review or ordering labs, 90792 is generally the correct code.
Required Documentation for CPT 90792
Payers expect documentation that supports the comprehensive nature of the evaluation. Thorough documentation protects against audits, improves care quality, and justifies reimbursement.
1. Patient History
Include:
- Presenting problems
- Psychiatric symptoms
- Medical history
- Social, trauma, and developmental history
- Substance use history
2. Mental Status Examination (MSE)
A complete MSE typically covers:
- Appearance
- Mood and affect
- Speech
- Thought content
- Cognition
- Insight and judgment
3. Risk Assessment
Evaluate for:
- Suicidal or homicidal ideation
- Psychosis
- Substance intoxication
- Acute medical instability
4. Medical Components
This is essential for 90792. Examples include:
- Reviewing vital signs
- Performing a physical exam if clinically indicated
- Lab/imaging review
- Reviewing comorbid medical diagnoses
- Medication management considerations
5. Diagnostic Formulation
Providers should include:
- Differential diagnoses
- Initial DSM-5 diagnosis(es)
- Rationale
6. Treatment Plan
This is critical for demonstrating clinical decision-making:
- Medications initiated or adjusted
- Therapy recommendations
- Safety plans
- Short- and long-term goals
When 90792 Can Be Billed
1. Initial Patient Evaluation
90792 is most commonly billed for a patient’s first psychiatric appointment.
2. Re-Evaluation After Extended Time
It may also be billed again when:
- A patient has been absent for extended periods
- Significant new medical or psychiatric conditions arise
- A full diagnostic overhaul is needed
3. Telehealth (Modifier 95)
90792 is frequently used in telemedicine with Modifier 95 when permitted by payers. Documentation must clearly indicate:
- Location
- Modality
- Technical requirements
4. Coordinated Care Cases
If the provider must review extensive medical records or collaborate with other clinicians, this code is appropriate.
Common Billing Mistakes to Avoid
1. Billing 90792 Without Medical Components
If no medical services are provided, payers may deny the claim because it should have been billed as 90791.
2. Copy-and-Paste Documentation
Auditors look for:
- Repetitive MSE entries
- Identical histories
- Non-specific treatment plans
3. Failing to Document Medical Necessity
Examples of strong documentation:
- “Patient presents with worsening depression requiring evaluation of medication response.”
- “Medication reconciliation performed to address polypharmacy concerns.”
4. Using 90792 for Medication-Only Visits
90792 is for diagnostic evaluation, not routine follow-ups. Medication management follow-ups require E/M coding (e.g., 99214).
Best Practices for Providers
1. Use Structured Templates
Providers who use structured templates often produce more complete documentation.
2. Clarify the Medical Components
Explicitly state activities such as:
- “Reviewed CBC results indicating mild anemia.”
- “Physical exam performed due to dizziness complaint.”
3. Align Documentation With Complexity
If the patient presents with multiple comorbidities, explain how these affect psychiatric care.
4. Explain Time Spent (If Required by Payer)
While CPT 90792 is not time-based, insurers may request clarification when audits occur.
Conclusion
CPT 90792 is an essential code for psychiatric providers who conduct comprehensive, medically informed evaluations. Proper documentation, understanding of medical components, and a structured approach to assessment ensure clean claims, enhance payer compliance, and improve patient outcomes. As behavioral health expands, accurate use of 90792 becomes foundational for clinical and financial success.
