CPT 90791 is a psychiatric diagnostic evaluation without medical services. CPT 90792 is the same evaluation with medical services, such as physical exam elements, prescribing or ordering labs, so it's generally limited to physicians and to nurse practitioners, physician assistants and clinical nurse specialists working within state scope. Both codes are untimed and billed once per day, and Medicare won't pay either one alongside psychotherapy or an E/M visit by the same provider on the same date.
Below: who can bill each code, what "untimed" means, frequency limits at Medicare, two Medicaid programs and a commercial plan, same-day NCCI rules, 90785, documentation, 2026 payment and denials. For the time-based codes that usually follow an intake, see our guide to psychotherapy CPT codes 90832, 90834 and 90837.
The short version
- 90792 adds a medical assessment to 90791, so the clinician's license has to cover medical work. LCSWs, counselors, MFTs and most psychologists bill 90791.
- Both codes are untimed: one unit per day, however long the evaluation runs. Separate evaluations with the patient and with informants on different days can each be reported.
- Under the 2026 NCCI Policy Manual, neither code is billed with psychotherapy or an E/M service on the same date by the same provider. The 90785 add-on is allowed.
- Medicare treats the evaluation as a once-per-episode service, repeatable after a treatment break of about 6 months, an inpatient admission or a significant change. Medicaid and commercial plans often cap it at one per provider per year.
- 2026 Medicare national office amounts are $173.35 for 90791 and $202.08 for 90792. Facility rates for both fell from 2025.
What 90791 and 90792 describe
Both codes cover the same core work. First Coast's psychiatric codes LCD (L33252) calls the basic evaluation "an integrated biopsychosocial assessment": history, psychiatric history, a complete mental status exam, a tentative diagnosis and a judgment about whether the patient can and will take part in treatment.
90792 adds the medical layer: physical exam elements as indicated, and possibly prescribing and reviewing or ordering labs and other studies. CMS's NCCI manual puts it bluntly. 90791 is the evaluation without medical E&M, and 90792 is the evaluation with medical E&M.
| Code | Descriptor | What it includes | Typical billers | 2026 Medicare national (office / facility) |
|---|---|---|---|---|
| 90791 | Psychiatric diagnostic evaluation | History, mental status exam, diagnosis, treatment recommendations | Psychiatrists, psychologists, LCSWs, counselors, MFTs, psychiatric NPs | $173.35 / $137.28 |
| 90792 | Psychiatric diagnostic evaluation with medical services | Everything in 90791, plus exam elements, prescribing, labs and other studies | Physicians, and NPs, PAs and CNSs within state scope | $202.08 / $159.32 |
| +90785 | Interactive complexity (add-on) | Communication factors that complicate the service | Whoever bills the primary code | $14.70 / $11.69 |
For the wider code set, see our CPT codes guide for behavioral health.
What "untimed" means
Neither descriptor carries a time. That cuts both ways. There's no minimum to reach, unlike the 16, 38 and 53-minute psychotherapy thresholds, and no extra unit for a long intake: a 50-minute evaluation and a two-hour one are each a single unit. WPS's psychiatry LCD (L34616) allows one evaluation per day, and Medicare's practitioner MUE for each code is one unit.
Long evaluations are handled by days, not minutes. L34616 allows separate evaluations with the patient and with other informants, so a parent interview on Monday and the child's interview on Wednesday can each be billed under the patient's name. We'd still record start and stop times. If a clinician bills six in one day, the times should add up.
Who can bill 90791 and 90792
The test is scope of license, not job title. A clinician licensed to diagnose mental illness can generally bill 90791. 90792 needs a license that covers medical services: First Coast's billing article (A57520) frames it as an option for "the physician or non-physician practitioner," who may use 90792 or an E/M code.
| Practitioner (Medicare) | 90791 | 90792 | Medicare pays |
|---|---|---|---|
| Physician (psychiatry, addiction medicine, primary care) | Yes | Yes | 100% of the fee schedule |
| Nurse practitioner, clinical nurse specialist | Yes | Yes, within state scope | 85% of the physician amount |
| Physician assistant | Yes | Yes, within state scope and supervision rules | 85% of the physician amount |
| Clinical psychologist | Yes | Generally no | 100% of the fee schedule |
| Clinical social worker | Yes | No | 75% of the clinical psychologist amount |
| Marriage and family therapist, mental health counselor (since January 1, 2024) | Yes | No | 75% of the clinical psychologist amount |
"Generally no" for psychologists is deliberate: Indiana Medicaid lets an HSPP (health service provider in psychology) render 90792. When the NPI, taxonomy and license on the claim don't fit the code, expect a provider-type denial.
90792 or a new-patient E/M visit?
Prescribers have a real choice. WPS's billing article (A57480) allows an E/M service in place of the initial interview if the E/M's required elements are met. It matters when the prescriber also does psychotherapy at intake: 90792 can't be billed with psychotherapy that day, but an E/M can carry the add-ons 90833, 90836 or 90838 when both services are significant and separately identifiable.
At 2026 national office rates, 90792 pays $202.08. A level 4 new-patient visit (99204) pays $177.36, and adding 30 minutes of psychotherapy (90833) brings the pair to $258.86. That gap isn't a reason to switch codes. It's a reason to code what happened, choosing the E/M level on medical decision making rather than time, as A57480 requires when psychotherapy add-ons are billed.
Medicaid programs that want H0031 or H0001
Some Medicaid programs and managed care plans route non-physician assessments to H0031 (mental health assessment, by non-physician) or H0001 (alcohol and/or drug assessment). Both are status I, not valid for Medicare, in the 2026 fee schedule file. The state manual and MCO contract decide. In SUD programs, the assessment you bill should agree with the level of care decision, as our ASAM documentation guide explains.
How often you can bill an evaluation
Medicare treats the evaluation as an onset-of-illness service. First Coast (L33252) and WPS (A57480) both allow it once at onset, with a repeat by the same provider after a treatment break of approximately 6 months. First Coast also allows a repeat for an inpatient psychiatric admission or a significant change in mental status.
Read the 6 months carefully. First Coast measures it from the last time the patient was seen or treated, not from the last evaluation, and says routine re-evaluation of chronic patients isn't medically necessary. So a patient in continuous weekly therapy doesn't earn a new 90791 at month seven, while a patient admitted to inpatient psychiatric care at month four can get one, if the note says why.
| Payer | Limit | Exceptions | Source |
|---|---|---|---|
| Medicare (First Coast, WPS) | Once at onset of illness, then after a treatment break of about 6 months. Once per day. | Inpatient psychiatric admission, significant change in mental status, separate informant evaluations on different days | L33252, L34616, A57480 |
| Indiana Medicaid (IHCP) | 1 unit of 90791 or 90792 per member, per provider, per rolling 12 months without prior authorization | 2 units when a physician or HSPP and another BH practitioner each evaluate the member. More with prior authorization. | IHCP Behavioral Health Services module, version 4.6 (October 2026), citing 405 IAC 5-20-8(14) |
| Ohio Medicaid | 1 encounter per recipient, per billing provider, per calendar year | More with prior authorization. SUD assessments are capped separately at 2 per calendar year per billing agency. | Ohio Admin. Code 5160-27-02 |
Notice the unit of measure. Indiana counts per provider over a rolling year, Ohio per billing provider over a calendar year. Commercial plans set their own frequency edits, often per member per year, so read the current reimbursement policy for each plan. A patient evaluated in December and readmitted in February is fine under Ohio's count and over the limit under Indiana's. Build the frequency edit for each payer, not one house rule.
Same-day rules: E/M, psychotherapy and NCCI
The 2026 NCCI Policy Manual is explicit. Because psychotherapy includes continuing psychiatric evaluation, 90791 and 90792 aren't separately reportable with individual, group, family, crisis or other psychotherapy codes for the same date. E/M codes such as 99202 to 99215 "shall not be reported with either." A modifier doesn't change that policy.
| Billed on the same date by the same provider | With 90791 or 90792? | Rule |
|---|---|---|
| E/M visit (99202 to 99215 and others) | No | NCCI manual, Chapter XI |
| Psychotherapy 90832 to 90838, family 90846 and 90847, group 90853 | No | NCCI manual, Chapter XI |
| Crisis psychotherapy 90839, 90840 | No | NCCI manual, A57520, A57480 |
| Interactive complexity +90785 | Yes, with a documented qualifying factor | L33252, A57480 |
| Alcohol or substance structured assessment and intervention G0396, G0397 | No | NCCI manual, Chapter XI |
| Neurobehavioral status exam 96116, 96121 | No | NCCI manual, Chapter XI |
| Psychological testing and evaluation 96130 to 96146 | Yes, if distinct, with no time counted twice | NCCI manual, Chapter XI |
NCCI edits apply per provider: same provider, same patient, same date. A therapist's 90791 and a primary care physician's E/M that day don't collide. Indiana Medicaid goes further for two-clinician intakes, allowing a second evaluation unit when a physician or HSPP and another BH practitioner each evaluate the member.
Run a multidisciplinary intake with each clinician on their own line, NPI and note, and book the first psychotherapy session for a later date. Indiana bars psychotherapy on the evaluation day without limiting that to the same clinician.
When the 90785 add-on is allowed
90785 pays for communication factors that make the service harder, not for a harder patient. First Coast's LCD and the Indiana Medicaid module list the same four factors, and the record must show at least one:
- Maladaptive communication among participants, such as high anxiety, high reactivity, repeated questions or disagreement, that complicates care.
- Caregiver emotions or behaviors that interfere with carrying out the treatment plan.
- A sentinel event with a mandated report to a third party, discussed with the patient and other participants.
- Play equipment, physical devices, an interpreter or a translator used to overcome barriers with a patient who isn't fluent in the same language or lacks expressive language skills.
It rides on 90791, 90792, psychotherapy (90832 to 90838) or group psychotherapy (90853). It isn't reported with crisis psychotherapy, and A57480 bars it with an E/M visit when no psychotherapy is reported. It adds $14.70 nationally in 2026. Small per claim. Across a year of child and family intakes, missing it adds up.
The record test is specific. First Coast wants the rationale, the adaptations used and treatment recommendations, and A57520 says 90785 shouldn't be billed when the patient can't communicate by any means. "Parent present" doesn't qualify. "Parents interrupted and contradicted each other about the symptom timeline, so each was interviewed separately for 20 minutes" does.
What the record must show for each code
First Coast's LCD lists what the evaluation record should contain, a fair proxy for what other reviewers check. For whether the services that follow get paid, see our medical necessity documentation guide.
| Element | 90791 | 90792 | What reviewers look for |
|---|---|---|---|
| Reason for evaluation, referral source | Yes | Yes | Chief complaint in the patient's words, and who referred |
| History of present illness | Yes | Yes | How long the symptoms have existed, not just a diagnosis |
| Psychiatric, medical, social and family history | Yes | Yes | Prior treatment and hospitalizations, substance use, family psychiatric history |
| Current medications | Yes | Yes, with decisions | A reconciled list. For 90792, what was started, changed or stopped, and why |
| Mental status exam | Complete | Complete | Every domain described, not "WNL" on a checklist |
| Strengths and liabilities | Yes | Yes | Something the treatment plan can build on |
| Diagnostic impression | Yes | Yes | ICD-10-CM codes that match the narrative and the claim |
| Treatment plan or recommendations | Yes | Yes | Methods, anticipated length, measurable goals |
| Physical exam, prescribing, labs | Not part of the code | As indicated | Exam elements tied to the clinical question, orders, results reviewed |
| Informants | If used | If used | Who and their relationship. If seen instead of the patient, the specific reason |
| Interactive complexity | If 90785 billed | If 90785 billed | The qualifying factor and the adaptation used |
We'd add two items the LCD doesn't list. Document a suicide and violence risk assessment, because an evaluation without one is hard to defend in any review. And for SUD, record quantity, frequency, route and last use for each substance, so the evaluation supports the level of care decision that follows.
Free template
Biopsychosocial assessment template (Word)
An editable template for the intake assessment that feeds the diagnostic evaluation, so history, mental status and recommendations are captured before the evaluation note is written.
Get the biopsychosocial assessment template Free, with a work email.
2026 Medicare payment, place of service and telehealth
These are 2026 national amounts from CMS Physician Fee Schedule data at the $33.4009 conversion factor that applies to most clinicians. Qualifying APM participants get $33.5675. Your MAC applies a geographic adjustment, so treat these as reference points.
| Code | 2026 office (non-facility) | 2026 facility | 2025 office | 2025 facility |
|---|---|---|---|---|
| 90791 | $173.35 | $137.28 | $166.91 | $142.97 |
| 90792 | $202.08 | $159.32 | $187.93 | $163.67 |
| +90785 | $14.70 | $11.69 | $14.23 | $12.29 |
The split is the 2026 story. Office rates rose and facility rates fell for both evaluation codes, after CMS finalized a policy recognizing greater indirect practice costs in offices than in facilities. In a hospital outpatient department, evaluation payments dropped even as the conversion factor rose. Non-physician practitioners get a share: a CSW's office allowance for 90791 is about $130.01, an NP's for 90792 about $171.77.
To find your rate, search 2026 pricing for the code in the CMS Physician Fee Schedule Look-up Tool and pick your MAC locality. Use the non-facility price for office visits and home telehealth, the facility price for facility settings, then apply the practitioner percentage. Check again each January.
Telehealth basics
All three codes are on the Medicare Telehealth Services List, and CMS covers behavioral health telehealth to the home permanently. Bill POS 10 when the patient is at home, paid at the non-facility rate, and POS 02 elsewhere. Add modifier 93 for audio-only visits, which Medicare allows for behavioral health at home, and FQ for audio-only services from an RHC or FQHC. Medicaid and commercial plans set their own POS and modifier rules, including modifier 95.
As of November 2026, CMS's Telehealth FAQ (updated October 8, 2026) says the in-person visit requirement for mental health telehealth takes effect after December 31, 2027. Patients who start home telehealth before then will need an in-person visit every 12 months after that date.
Common denials and how to fix them
| Typical CARC | What happened | Fix |
|---|---|---|
| CO-97 or CO-236 | 90791 or 90792 billed with psychotherapy, an E/M or a crisis code on the same date by the same provider | Bill only the evaluation that date, or recode the visit as E/M plus psychotherapy if that's what happened. Don't force the pair through with 59. |
| CO-119 | The payer's evaluation limit for the period was reached | Check the last evaluation date and provider before intake. Request prior authorization, or show a new episode. |
| CO-151 | The payer sees a repeat evaluation as too frequent | Appeal with the note showing the treatment break, the admission or the change in mental status |
| CO-8, CO-170 or CO-185 | Provider-type mismatch: 90792 by a clinician without medical scope, or an NPI or taxonomy that doesn't fit the code | Rebill 90791 if medical services were out of scope, or fix enrollment and taxonomy. Never move the service to another clinician's NPI to get paid. |
| CO-107 | 90785 without a qualifying primary service, for example with an E/M alone or a crisis code | Remove 90785, or bill it on the same claim as the code it supports |
| CO-50 | Evaluation not supported as medically necessary, often a repeat with no stated reason | Show the psychiatric illness or symptoms, and why an evaluation was needed now |
| CO-5 or CO-4 | POS or telehealth modifier doesn't fit the payer's rules | Correct the POS and the 93, FQ or 95 modifier, then send a corrected claim |
Track these by root cause, not by code. If CO-97 or CO-236 keeps landing on intake days, fix the scheduling template. If CO-8 clusters on one clinician, it's an enrollment problem, and no appeal will solve it. Our CO-50 appeal guide includes a letter template, and our CARC guide covers the rest of the list.
Pre-bill checklist for evaluation claims
- Right code for the work. Documented medical services mean 90792. Otherwise, 90791.
- Right code for the clinician. License, payer enrollment and taxonomy support it.
- No same-day conflicts. No psychotherapy, crisis, E/M, G0396, G0397, 96116 or 96121 by the same provider that date.
- One unit, unless a separate informant evaluation happened on a different date.
- Frequency checked against the payer's period: rolling year, calendar year or 365 days.
- Any repeat explained: a treatment break, an admission or a change in mental status.
- 90785 earned: a named qualifying factor and the adaptation used.
- Telehealth complete: POS, modifier, modality and patient location documented.
- Signed and dated with credentials before the claim goes out.
How Adentris helps
Most evaluation denials are decided before the claim leaves: the wrong code for the clinician, a psychotherapy line on the evaluation date, a 90785 with nothing in the note behind it. Autonomous Coding reads every claim line against the chart before billing. It flags under-coding, missing add-ons such as 90785, modifier errors, NCCI bundles, LCD gaps and codes that don't fit the provider type.
Behind it, Adentris reviews every active chart, not a sample, against payer and regulatory rules, and each finding cites the rule that fired and comes with a drafted correction for staff to approve. It runs on top of any EHR, through API or FHIR, HL7 feeds, an API our agents build where none exists, or the AI Web Agent, with AI inference inside Microsoft Azure. To see it on your own claims, book a 30-minute call with our team.
Related reading
- Psychotherapy CPT Codes 90832, 90834 and 90837 (plus 90791): Time Rules, Documentation and Denials
- Medical Necessity Documentation for Behavioral Health: What Payers Require
- Denial Codes in Behavioral Health: A CARC Guide for BH and SUD Programs (and How to Prevent Each)
Sources
- CMS, Medicare NCCI Policy Manual 2026, Chapter XI (psychiatric services) and Chapter I (scope of PTP and MUE edits)
- CMS, Medicare NCCI Medically Unlikely Edits
- LCD L33252, Psychiatric Codes (First Coast) and billing article A57520
- LCD L34616, Psychiatry and Psychology Services (WPS) and billing article A57480
- CMS, Medicare and Mental Health Coverage (MLN1986542, March 2026)
- CMS, Marriage and Family Therapists and Mental Health Counselors
- CMS, Physician Fee Schedule Look-up Tool and PFS data (2025 and 2026 indicator files)
- CMS, CY 2026 Physician Fee Schedule final rule fact sheet
- CMS, Telehealth FAQ (updated October 8, 2026)
- First Coast Service Options, Telehealth service modifiers
- X12, Claim Adjustment Reason Codes
- Indiana Health Coverage Programs, Behavioral Health Services provider reference module (version 4.6)
- Ohio Admin. Code 5160-27-02 (behavioral health coverage limits)
Frequently asked questions
What is the difference between CPT 90791 and 90792?
90791 is a psychiatric diagnostic evaluation without medical services. 90792 is the same evaluation with medical services, such as physical exam elements, prescribing medication, or ordering and reviewing labs. Bill 90792 only when that medical work was done and the clinician's license covers it.
Can a therapist or LCSW bill 90792?
Generally no. 90792 includes medical services, so physicians, nurse practitioners, physician assistants and clinical nurse specialists bill it within state scope. LCSWs, counselors, marriage and family therapists and most psychologists bill 90791. Indiana Medicaid is one exception that lets an HSPP render 90792.
How often can 90791 be billed?
Medicare contractors allow it once at the onset of illness, with a repeat after a treatment break of about 6 months, an inpatient psychiatric admission or a significant change in mental status, and never more than once a day. Indiana Medicaid allows one per member, per provider, per rolling 12 months without prior authorization, and Ohio Medicaid one per billing provider per calendar year.
Can you bill 90791 and 90837 on the same day?
Not for the same provider under Medicare. The 2026 NCCI Policy Manual says 90791 and 90792 are not separately reportable with individual, group, family, crisis or other psychotherapy codes on the same date, and E/M codes cannot be reported with either. Schedule the first psychotherapy session for a later date.
Is 90791 a timed code?
No. Neither 90791 nor 90792 has a time in its descriptor, so the evaluation is one unit whether it takes 45 minutes or two hours. Separate evaluations with the patient and with informants on different days can each be reported.
How much does Medicare pay for 90791 in 2026?
The 2026 national amount is $173.35 in an office and $137.28 in a facility, before geographic adjustment. For 90792 it is $202.08 and $159.32. Social workers, marriage and family therapists and counselors get 75% of the clinical psychologist amount, and NPs, PAs and CNSs 85% of the physician amount.
