Psychiatric Diagnostic Evaluations

Use these codes when completing an initial psychiatric diagnostic evaluation.

CPT codes

90792 — Psychiatric diagnostic evaluation (with medical services)

Self-pay (internal)

999205 — Self-pay initial
999214 — Self-pay follow up

Established Patient E/M Visits (99213–99215)

Choose the level based on overall medical decision-making (MDM). The examples below are to guide consistency and documentation.

MDM quick table (psychiatry examples)

Code (level)	Problem Type	Examples
99213 Low	• 1 stable chronic illness • 2+ self-limited conditions • 1 acute, uncomplicated illness/injury	• Mild situational stress, no ongoing diagnosis • Adjustment disorder resolving, no meds • Recheck on sleep concerns without med use
99214 Moderate	• 1+ chronic illness with mild exacerbation, side effects, or progression • 2+ stable chronic illnesses • 1 undiagnosed new problem with uncertain prognosis	• ADHD (stable or not) on stimulants; reviewed, continued, or adjusted • Depression worsening, med change made • ADHD + anxiety, both discussed and managed • New onset panic attacks, diagnosis not yet confirmed
99215 High	• 1+ chronic illness with severe exacerbation or threat to life/function • Acute or chronic condition that poses immediate threat to life/function	• Suicidal ideation with plan • Bipolar I manic episode with high-risk behaviors • Psychosis, hallucinations, or dangerous delusions • Initiation of high-risk meds (example: lithium or clozapine) with close monitoring needed

When 99215 is appropriate

99215 is appropriate when the visit involves a high level of MDM or requires at least 40 minutes of total time on the date of the encounter. The progress note must clearly support this level through thorough documentation.

What your note must show

Complex psychiatric condition(s) and clear clinical reasoning
Medication management with significant risk (when applicable)
Crisis intervention and/or coordination with other providers (when applicable)
If billing by time: total time on date of service and what it included (evaluation, planning, coordination, counseling)

Not enough by itself

A long or difficult session without documented risk, complexity, and decisions
“Felt hard” without a defensible record of MDM or time-based requirements

See the AMA MDM grid for deeper explanations: AMA CPT revised MDM grid (PDF)

Modifiers

Use modifiers only when appropriate. Incorrect modifiers are a common audit risk.

Common modifiers

95 — Telehealth
25 — Distinct procedure (separately identifiable E/M when appropriate)
59 — Add-on / distinct service (use only when supported)

Telehealth tip: if telehealth, add 95 under both “mod 2” squares when required by workflow.

Quick rules (simple)

Use 25 for the E/M when a distinct service is also billed and documentation supports separateness
Use 59 only when the add-on truly qualifies and is defensible
If you can’t clearly explain “why this modifier is necessary,” don’t use it

Add-on psychotherapy codes (with E/M)

Use add-on codes only when psychotherapy is provided in addition to E/M and required elements are documented. Keep the E/M note high-level and protect sensitive details.

Add-on code selection

Add-on code	Time (min)	When to use	Example
+90833	16–37	Brief therapy provided in addition to E/M	Meds reviewed; provider addressed mood and taught coping skills
+90836	38–52	Extended therapy provided along with E/M	Meds managed; provider explored symptoms and provided therapy
+90838	52+	Full session of therapy performed along with E/M	Brief med check; full session spent on therapy and treatment planning

What goes in the E/M note (brief psychotherapy section)

Include only the elements required for billing:

Statement that psychotherapy was provided
Modality (CBT, DBT, EMDR, supportive therapy, etc.)
Psychotherapy time (for +90833, +90836, +90838)
High-level focus (examples: “Reviewed coping strategies for anxiety,” “Brief trauma-focused work,” “Continued CBT interventions for mood regulation”)

Important: do not include detailed session content or sensitive information in this section. This part of the note may be shared in routine record requests.

What belongs in a separate psychotherapy note (detailed content)

Document detailed narrative separately (protected unless explicitly authorized):

Trauma processing / EMDR target and reprocessing notes
Abuse history or disclosures
Detailed cognitive themes/distortions
Family conflict specifics
Specific examples, quotes, or emotional content
Anything not appropriate to disclose without explicit authorization

Treatment plan requirement: if you plan to continue therapy, a treatment plan is required within 30 days.

Modifier reminder: Use 25 for E/M and 59 for add-on only when supported and defensible.

Behavioral assessment code (96127)

96127 can be used during follow-up visits when medically necessary. Each screening billed must be individually documented.

Rules (quick)

96127 can be used during follow-up visits
1 unit per tool (commonly 1–4 per visit depending on payer policy)
Can only be billed 1x per quarter (per internal guidance)
Include screening encounter diagnosis when required (example: Z13.31 or other appropriate screening code)

Common tools

PHQ-9, GAD-7, Vanderbilt, RAAPS, SCARED
M-CHAT, AUDIT, CRAFFT

Documentation must include

Tool name
Score/result
Provider interpretation
Clinical relevance (why it was done and how it influenced care)

The record must clearly show the tool was administered, scored, and reviewed during the visit, and that the results were addressed as part of clinical decision-making.

Non-billable codes (internal guidance)

Do not use the following as billable primary diagnoses per internal guidance.

Do not use

G47.00
F51.01
Any codes other than F codes (I, R, Z, etc.) as primary diagnosis unless specifically appropriate

Rule of thumb: If it isn’t clearly supported in the note, don’t bill it.

Charge workflow (simple)

Follow this flow each time so nothing is missed before billing.

1

Select the correct CPT

Choose 90792, 99213–99215, or self-pay codes based on the service provided and documentation.

2

Confirm documentation supports the level

MDM must match the level billed. If billing by time, document total time and what it included.

3

Add psychotherapy add-ons only if documented

Include modality, time, and high-level focus in the E/M note; place detailed therapy narrative in a separate psychotherapy note.

4

Add 96127 only when fully documented

Tool + score + interpretation + clinical relevance must appear in the record for each screening billed.

5

Apply modifiers accurately

95 telehealth; 25 for distinct E/M; 59 for add-on only when supported.

6

Save progress

Once a charge is completed, hit Save progress so billing can review for anything missed before submission.

Reminder: I (try my best to) submit charges daily. Saving progress helps catch missed items before they go to billing.

Provider Coding & Compliance (Internal)