CPT Code for Comprehensive Psychiatric Diagnostic Evaluation in a Child
For this comprehensive behavioral health evaluation involving 50 minutes face-to-face time plus 20 minutes non-face-to-face time (70 minutes total), the appropriate CPT code is 90792 (Psychiatric diagnostic evaluation with medical services). 1
Rationale for Code Selection
CPT 90792 is specifically designed for psychiatric diagnostic evaluations that include medical assessment components, which this visit clearly demonstrates through the comprehensive evaluation of a 5-year-old with behavioral difficulties, developmental history review, medical history assessment (asthma, respiratory issues), and medication evaluation (hydroxyzine). 1
Key Documentation Elements Supporting 90792
The report includes all required components for 90792:
- Complete mental status examination covering appearance, behavior, speech, mood/affect, thought process and content, perception, cognition, and risk assessment 1
- Medical evaluation components including developmental milestone assessment, medical history (respiratory issues, asthma), current medication review (hydroxyzine), and evaluation of how medical factors may contribute to psychiatric presentation 1
- Comprehensive psychiatric history documenting presenting illness, family psychiatric history (brother with ADHD/ODD), developmental history, and psychosocial stressors 1
- Risk assessment with documentation of safety concerns, aggressive behaviors, and protective factors 1
Time-Based Billing Justification
The 70 minutes of total time (50 face-to-face + 20 non-face-to-face) supports billing 90792, as this code is not strictly time-based but rather based on the comprehensive nature of the evaluation. 1 The prolonged service codes (99354-99355) could potentially be added if the face-to-face time significantly exceeded typical expectations, but the base 90792 code appropriately captures this initial comprehensive diagnostic evaluation. 2
Alternative Coding Considerations (Not Recommended Here)
Do not use standard E/M codes (99201-99215) for this comprehensive psychiatric diagnostic evaluation, as 90792 is the specific psychiatric code designed for this service. 1, 3 The American Academy of Child and Adolescent Psychiatry emphasizes that psychiatric diagnostic evaluations should use psychiatric-specific codes rather than general E/M codes when the primary purpose is psychiatric assessment. 1
Do not use 90791 (psychiatric diagnostic evaluation without medical services) because this evaluation clearly included medical assessment components: review of medical history, developmental milestones, medication evaluation, and assessment of how medical factors (asthma, respiratory issues, medication effects) relate to psychiatric presentation. 1
Documentation Requirements Met
The report demonstrates medical complexity justifying 90792 through:
- Evaluation of medication side effects (hydroxyzine effectiveness assessment) 1
- Assessment of medical conditions contributing to psychiatric symptoms (asthma, respiratory history, developmental factors) 1
- Coordination considerations with other providers (ECAP program, previous clinician, potential child protective services involvement) 1
Common Pitfalls to Avoid
Avoid using developmental testing codes (96110,96111) as the primary code for this visit, as no formal psychometric assessments were administered during this session. 2 These codes are reserved for standardized developmental screening instruments with scoring and interpretation. 2
Do not bill 99490 or 99487 (chronic care management codes) for this initial diagnostic evaluation, as these codes are specifically for ongoing monthly management of established chronic conditions, not initial diagnostic assessments. 2
Ensure documentation specifically states which medical factors were evaluated and how they influenced psychiatric diagnosis and treatment planning, as this justifies the "with medical services" component of 90792. 1 This report adequately documents medical history, medication review, and developmental assessment.
Telemedicine Modifier (If Applicable)
If this evaluation was conducted via telemedicine, add modifier "95" to CPT 90792 when using interactive audio and video telecommunications, ensuring the patient was present and participating at the originating site. 1
Final Billing Recommendation
Bill CPT code 90792 for this comprehensive psychiatric diagnostic evaluation with medical services. 1 The 70 minutes of total time, comprehensive nature of the evaluation, inclusion of medical assessment components, and detailed documentation all support this code selection. The report meets all documentation requirements specified by the American Academy of Child and Adolescent Psychiatry for psychiatric diagnostic evaluations with medical services. 1