CPT Code 90792: Criteria and Usage
CPT code 90792 is designated for a psychiatric diagnostic evaluation with medical services, which includes a comprehensive mental status examination, assessment of medical factors affecting psychiatric presentation, and medical decision-making that incorporates both psychiatric and medical considerations. 1
Core Components Required for 90792
The psychiatric diagnostic evaluation coded as 90792 must include:
Complete mental status examination covering appearance, behavior, speech fluency and articulation, mood and affect, thought process and content, perception, cognition, and current risk assessment 2, 3
Medical evaluation components including assessment of vital signs, physical examination findings relevant to psychiatric presentation, review of current medications, and evaluation of medical conditions that may contribute to psychiatric symptoms 2, 3
Comprehensive psychiatric history documenting history of present illness, past psychiatric diagnoses and treatments, substance use history, family psychiatric history, and psychosocial stressors 3
Risk assessment with specific documentation of current suicidal ideation (including plans, intent, access to means, and protective factors), aggressive or homicidal thoughts, and estimated level of risk with influencing factors 2, 3
Key Distinction: 90792 vs 90791
The critical difference is that 90792 includes medical services and medical decision-making, while 90791 is a psychiatric diagnostic evaluation without medical services. 1 Clinical psychologists and clinical social workers cannot bill for 90792 under Medicare, as they are not authorized to provide medical evaluation and management services. 1
Documentation Requirements
Your documentation must support:
Medical complexity justifying the inclusion of medical services, such as evaluating medication side effects, assessing medical conditions contributing to psychiatric symptoms, or coordinating care with medical providers 2, 3
Time and complexity of the evaluation, which typically requires 60-90 minutes for an initial comprehensive psychiatric evaluation with medical services 4
Treatment rationale including specific factors that influenced treatment selection and how medical considerations affected psychiatric treatment planning 2, 3
Telemedicine Billing
CPT code 90792 can be billed via telemedicine with modifier "95" when:
Interactive audio and video telecommunications system is used permitting real-time communication between provider and patient 1
Patient is present and participating in the evaluation at the originating site 1
The service meets all standard documentation requirements for 90792 1
Common Pitfalls to Avoid
Do not use 90792 for routine follow-up visits - this code is specifically for diagnostic evaluations, typically initial assessments or comprehensive re-evaluations when clinical presentation has significantly changed. 4
Ensure medical components are documented - if you cannot justify the medical evaluation and medical decision-making components, use 90791 instead to avoid claim denials. 4
Avoid mixing with same-day E/M codes - when a patient is evaluated in clinic and then admitted to hospital on the same day, the evaluation services should be incorporated into the initial hospital care code (99221-99223), not billed separately as 90792. 5
Document specific medical factors - vague statements about "medical clearance" are insufficient; specify which medical conditions, medications, or physical findings were evaluated and how they influenced psychiatric diagnosis and treatment. 2, 3