Wiki Documentation requirements for CPT code 90791 - Psychiatric diagnostic evaluation

[medicalauditor]

I am looking for detailed documentation requirements for 90791 - Psychiatric diagnostic evaluation. The CPT code book does not really elaborate on what should be documented. I can't find anything from CMS either. I did find a fact sheet by CGS which states that the following must be documented:
• Elicitation of a complete medical and psychiatric history (including past, family, social)
• Mental status examination
• Establishment of an initial diagnosis
• Evaluation of the patient’s ability and capacity to respond to treatment’
• Initial plan of treatment
However, we have Novitas in Texas, and I can't find anything from them. I would appreciate it if someone can help with a CMS resource or any other MAC. I am looking specifically for documentation requirements which state that complete history including FAMILY and SOCIAL history must be documented, and a MSE, as stated by CGS. Our providers don't document family and social history and don't document a detailed mental status exam - they just document "within normal limits" which I feel is not sufficient. If I just quote the CGS resource, there will be pushback, so I am looking for CPT, AMA, CMS or any other valid resource. Thank you!

 

[amyjph]

That's just shoddy. If every one is just WNL, what does the rest of the note look like? Can they just do that? I guess, but why would they want to, it's crappy documentation.
Novitas:
General psychotherapy documentation "checklist" https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00171100

https://www.cms.gov/medicare-medicaid-coordination/fraud-prevention/medicaid-integrity-education/downloads/docmatters-behavioralhealth-factsheet.pdf

General documentation info: https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00229507 (look under key point in this one)
General TPE results & activity (not specific to 90791, but helpful): https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00270108

https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00092535

https://www.cms.gov/files/mln909160-complying-with-medical-record-documentation-requirements.pdf

https://www.cms.gov/training-education/medicare-learning-networkr-mln/compliance/medicare-provider-compliance-tips/outpatient-psychiatric-care

From Novitas found here:

https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=35101&ver=128&keyword=psych&keywordType=all&areaId=all&docType=F&contractOption=name&contractorName=6&sortBy=relevance&bc=1

Specific Documentation Requirements

Section I: Psychiatric Diagnostic Evaluation

The medical records must reflect in legible form the elements outlined in the above description of the services and contain all of the following elements:
Date
Referral source
Length of session (these are not timed codes; however, the standard length of time is generally considered to be between 45 minutes and one hour)
Content of session Therapeutic techniques and approaches, including medications Assessment of the patient’s ability to adhere to the treatment plan Identity of person performing service (legible signature) For interactive therapy, the medical record should indicate the adaptations utilized in the session and the rationale for employing these interactive techniques. For services that include an E/M component, the E/M services should be documented. The medical records must indicate the diagnosis, including psychological and/or medical conditions, as well as any psychosocial and environmental stressors.

In CPT at the beginning of the 90791 there is a definition but it doesn't explicitly state what they must document. The first couple sentences might help.

See pg 10 of this: https://www.apaservices.org/practice/reimbursement/health-codes/testing/billing-coding.pdf

Not your MAC but see here: https://www.tmhp.com/sites/default/.../2025-09-september/2_02_behavioral_health.pdf
4.2.6 Psychiatric Diagnostic Evaluation Services
Psychiatric diagnostic evaluation is an integrated biopsychosocial assessment, including history, mental status, and recommendations. Psychiatric diagnostic evaluation with medical services also includes a medical assessment, other physical examination elements as indicated, and may also include prescription of medications, and laboratory or other diagnostic studies.