90791 Psychiatric evaluation Medicare reimbursement rates in Arkansas

A clinician uses this evaluation to assess a behavioral health concern, establish or clarify a diagnosis, and recommend treatment. The work includes psychiatric and psychosocial history, a mental status examination, and review of relevant medical history. Information may also come from family members, caregivers, or prior records. Psychologists, clinical social workers, and mental health counselors commonly perform the assessment in offices, community settings, hospitals, or by telehealth. A psychiatrist or psychiatric nurse practitioner may use this code when the evaluation includes no medical services.

Select 90791 for the diagnostic evaluation rather than a psychotherapy visit focused on treatment or 90792 when medical services are furnished as part of the evaluation. Document the presenting problem, relevant history, mental status findings, diagnostic impression, and plan. The code is not time-based: assign units for distinct, medically necessary evaluations, not for minutes or interview segments. A further evaluation on another date needs documentation supporting why additional diagnostic work was necessary. Do not separately report psychotherapy or an E/M service furnished by the same clinician as part of this evaluation. Interactive complexity may be reported when its specific requirements are met and documented.