Q&A: Documentation requirements for psychiatric assessment CPT code 90792

Q: Does a psychiatrist need to document a physical examination and a review of prescriptions in order to support the reporting of CPT code 90792 (psychiatric diagnostic evaluation with medical services)?

A: CPT codes 90791 (psychiatric diagnostic evaluation) and 90792 are typically reported when the psychiatrist first sees a patient but may also be used for a new episode of illness.

As stated in the CPT Manual, a psychiatric diagnostic evaluation must include an assessment of history, mental status, and recommendations. It may include communication with family or other sources, prescription of medications, and ordering of laboratory studies.

To support the reporting of 90792, the psychiatrist must document one or more medical services, which can include elements of a physical examination, writing a prescription, or modifying psychiatric treatment.

Notably, neither codes can be reported with an E/M or psychotherapy service on the same day by the same provider. Each code may only be reported once per day. These codes may be reported together on the same day if the 90791 assessment is completed by a clinician and the 90792 assessment is completed by a psychiatrist.

Editor’s note: Shelley C. Safian, PhD, RHIA, CCS-P, CPC-H, CPC-I, of Safian Communications Services Inc. in Longwood, Florida, is an AHIMA-approved ICD-10-CM/PCS trainer answered this question during the HCPro webinar, “Outpatient Documentation and Coding for Behavioral Health.”

This answer was provided based on limited information submitted to JustCoding. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.

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