Psychiatric Medical Billing And Coding Procedures

CPT Code 90791 – Psychiatry medical billing Diagnostic Evaluation

This code is used for a comprehensive psychiatry medical billing diagnostic evaluation. It involves healthcare professionals such as MDs, NPPs, and LMSWs. It also provides complete guidelines for other health professionals like LCSWs, Licensed Psychologists, and LCATs.

Documentation Requirements:

This code requires a complete medical and psychiatric history of the patient. This document must contain, all important information regarding the past medical conditions of a patient and the genetic domains of his family. Furthermore, this document must also have details of the social aspects of the patient. This code requires pre-mental status examination before going into in-depth mental analysis. That is the reason, a document containing a complete record of all previous and ongoing treatment must be presented in a separate document.

Establishing an initial diagnosis is imperative for further diagnostic evaluation. That is the reason a document should be attached that must have details of all initial diagnoses. This document is imperative from the perspective of the healthcare provider because after viewing this document he can make rational judgment regarding the existing status of the patient.  Evaluation of a patient’s ability and capacity to respond to a provided treatment is quite imperative. That is the reason, the document must be attached containing the resistance level and bearing capacity of the patient. This helps healthcare professionals to increase or decrease the dose.

This code can be reported once per day which means it should not be billed on the same day as an E/M service performed by the same individual for the same patient. The details of such treatment must be attached in documentary form. Read More...