Understand the ins and outs of CPT codes to help make documentation and billing more efficient — and give you more time to focus on other areas of your practice.
Billing and coding
How to use CPT code 90791 for intake sessions
Code 90791 is officially a “diagnostic evaluation,” but you might know it better as an initial assessment. Learn how to bill your first session with a client.
December 21, 2023 • Updated on October 16, 2026
By the Headway Editorial Team
13 min read
By the Headway Editorial Team
What to know
1
CPT code 90791 is used for a psychiatric diagnostic evaluation, typically during an intake appointment with a new client.
2
CPT code 90791 is not a time-based code.
3
Use code 90791 only if your diagnostic evaluation didn’t include medical services; if it did, use code 90792.
4
Headway makes insurance billing a breeze with comprehensive claims support, saving providers the headache of denied or delayed payments.
CPT code 90791 description
Code 90791 represents your initial assessment of your client. It’s the session where you gather information about the clients symptoms in order to establish a diagnosis and formulate their treatment plan.
This is is how the American Medical Association defines 90791 in the official CPT codebook:
Psychiatric diagnostic evaluation (without medical services)
Psychiatric diagnostic evaluation is an integrated biopsychosocial assessment, including history, mental status, and recommendations.
The evaluation may include communication with family or other sources and review and ordering of diagnostic studies.
Many types of licensed mental health providers can use CPT code 90791.This code is most frequently used by:
- Licensed Clinical Social Workers (LCSW)
- Licensed Professional Counselors (LPC)
- Licensed Marriage Family Therapists (LMFT)
- Clinical Psychologists (CP)
- Licensed Psychologists (LP)
Is 90791 the right code for an intake session?
Yes, code 90791 is commonly used for an intake session. Typically, prior authorization is not required to use this code.
Your documentation for this code should include all the standard elements of an intake note, including:
- Session details: Including patient name and date of birth on every page, start and stop times, date, and place of service
- History of present illness
- Biopsychosocial assessment
- Mental status exam (at least 5 elements)
- Risk assessment
- Initial plan of treatment and plan for next session
- Diagnosis and functional status
- Name, credentials and signature of provider who completed assessment within 72 hours of service
Complete documentation for 90791 should include both the intake note and your bio-psycho-social assessment, as well as any diagnostic-specific assessment like the PHQ-9 for depression, GAD 7 for anxiety, or the Alcohol Use Disorders Identification Test (AUDIT-C) for substance abuse.
It’s important to use the code that most accurately reflects the time you spent with the patient to treat their condition, and ensure that documentation for the session supports the chosen code.
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CPT code 90791 time frame
- Is it time-based?: No, 90791 is not associated with any specific time component
- Typical session length: Clinicians often spend 45 minutes or more conducting a full assessment
- Minimum documented time: 90791 is not a time-based code.
CPT code 90791 reimbursement rates
Reimbursement rates for sessions billed with 90791 will vary depending on the plan, your contract, your location, and your license type. The right partnership can boost reimbursement rates, too.
Headway has strong relationships with many of the nation’s top insurance carriers, allowing us to negotiate competitive reimbursement rates that make accepting insurance both easy and profitable for our providers. Headway providers can earn around $27,000 more per year than they would through self-credentialing.
How often can CPT code 90791 be billed for one client?
Many payers will only reimburse 90791 once per year, per client. Some allow it to be used only once per patient, per episode of care. If a patient leaves therapy and returns after a long gap, it may be appropriate to use code 90791 again, since their return kicks off a new episode of care.
Code 90791 cannot be reported on the same day as an evaluation and management service for the same patient, or on the same day as psychotherapy services (including for crisis). Use code 90785 in conjunction with 90791 when the diagnostic evaluation includes interactive complexity services.
What’s the difference between 90791 and 90792?
Code 90791 is used to represent an intake assessment for care that does not include medical services.
In contrast, code 90792 is used for an intake assessment for care that does include medical services, such as ordering diagnostic work or prescribing medications. For this reason, 90792 can only be billed by a qualified licensed provider like a psychiatrist or nurse practitioner.
This document is intended for educational purposes only. It is designed to facilitate compliance with payer requirements and applicable law, but please note that the applicable laws and requirements vary from payer to payer and state to state. Please check with your legal counsel or state licensing board for specific requirements.
Add-on codes that are often used with CPT code 90791
Several billing codes may be used along with CPT code 90791. These include:
- Code 90785, which is used for appointments with “interactive complexity,” such as working with a non-verbal child or also communicating with a third party, like a family member or probation officer.
- Code 99354, which is used for extended intake sessions that last from 91-150 minutes.
- Code 99355, which is used for each additional 30 minutes that a session lasts beyond 150 minutes.
Remember that code 90791 is used for sessions that do not include medical services. If you’re looking to add on codes for medical services, you’ll likely need to use code 90792 instead.
Billing 90791 for telehealth sessions
If an intake session occurs over telehealth, you can still use CPT code 90791. Just remember that some additional information is required when you bill for telehealth appointments.
For example, you’ll need to include place of service and CPT modifier codes to indicate the appointment occurred over telehealth. Commonly, providers use the place of service codes 10 or 02 (for synchronous appointments that took place while the client was in or outside their home, respectively) and the CPT modifier code 95 (which denotes a synchronous appointment conducted on platforms such as a HIPAA-compliant version of Zoom).
Common mistakes when billing CPT code 90791
In addition to confusing codes 90791 and 90792, as discussed above, providers may run into difficulty if they try to use code 90791 repeatedly for the same patient. Typically, it can only be used once per patient, per year. It should not be used for follow-up visits or on the same day as psychotherapy services are delivered.
Another common mistake is failing to provide enough documentation along with code 90791. Make sure you’ve included all relevant components listed above. Headway providers can use the platform’s included intake and documentation templates to make sure nothing falls through the cracks.
FAQs about CPT code 90791
What is the difference between 90791 and 90837?
CPT code 90791 is used for an initial assessment and diagnosis of a client, typically during an intake session. Code 90837, meanwhile, is used for regular, ongoing care. It describes a 60-minute psychotherapy session.
Can 90791 and 90837 be billed on the same day?
Generally, no. An assessment appointment is considered separate from treatment.
How many times can you bill 90791 in a year?
Payers set their own limits. Some reimburse code 90791 only once per patient, per episode of care. Others reimburse it once per patient every year, or even every six months.
How much does Medicare pay for 90791?
As of 2026, Medicare reimburses psychologists billing code 90791 at around $173. Rates may vary for other license types, as well as for providers billing commercial plans.
Is 90791 a time-based code?
No, 90791 is not associated with any specific time component. But make sure to document other session details, including the client’s personal information, place of service, and your full assessment of their condition.
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This content is for general informational and educational purposes only and does not constitute clinical, legal, financial, or professional advice. All decisions should be made at the discretion of the individual or organization, in consultation with qualified clinical, legal, or other appropriate professionals.
© 2026 Therapymatch, Inc. dba Headway. All rights reserved. No part of this publication may be reproduced without permission.
Billing and coding
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Understand the ins and outs of CPT codes to help make documentation and billing more efficient — and give you more time to focus on other areas of your practice.