CPT Codes for Initial Intake: 90791 & 90792

Initial intake codes are used at the start of the therapy treatment process to address new behavioral health concerns with a new client. The two most commonly used initial evaluation codes for mental health care are 90791 and 90792.

90791 and 90792 are typically single-visit codes to establish a diagnosis and treatment plan. Some payers may allow two visits if the evaluation cannot be completed in one session, but this is payer-dependent and requires medical necessity for the extension.

Whereas 90792 can only be used by prescribers, many different types of providers use 90791.

CPT Code: 90791

Description: Psychiatric Diagnostic Evaluation without Medical Services

Who can use it: Licensed mental health care providers including LCSW, LMHC, LPC, LMFT, etc.

Time Requirements: No strict minimum time is mandated, but documentation must support the full complexity of a psychiatric diagnostic evaluation. The typical session duration of 30-90 minutes is a reasonable guide.

CPT Code: 90792

Description: Psychiatric Diagnostic Evaluation with Medical Services

Who can use it: This code is typically used for prescribing medication and is only to be used by prescribers. E/M codes (99202–99205) are typically used by prescribers who prefer to code based on complexity (MDM) rather than the comprehensive diagnostic interview format of 90792.

Time Requirements: Minimum of 45 minutes and up to 120 minutes for a comprehensive assessment

How to use initial intake codes

Each code can be used for up to two sequential visits in one calendar year. The second visit is allowed in the event you need more than one 60-minute appointment to finish your initial evaluation.

Whether a provider can submit claims for one or two visits using the 90791 or 90792 CPT code is dependent on the client's insurance payer. At the beginning of care, it’s best to advise your client to reach out to their insurance plan for details on what is and isn’t covered.

More helpful tips:

• Insurance requires that these codes only be used for the first time you see a client. In this session, you can gather information about the client and formulate a treatment plan.
• If used for two sequential appointments, these sessions must occur on separate dates.
• You cannot switch between CPT codes if using 90791 or 90792 for sequential visits.
• Documentation for these codes must be a full, comprehensive Initial Psychiatric Evaluation/Intake that includes history, risk, mental status exam, diagnosis, and treatment plan.

• If there’s an episodic change in the patient's condition or mental health status, i.e., if a patient has had a significant change in their mental health (e.g., a major life event, a new diagnosis, change in symptoms, etc), CPT codes 90791 or 90792 may be used again.
• 90791 & 90792 can never be used with modifying codes, with one exception: If the session is held virtually, you should apply the “-GT” modifier which conveys that care was delivered via telehealth.