Nebraska Peace of Mind
90791 Initial Diagnostic Interview (IDI) Guide
A color-coded checklist for LIMHPs, LICSWs, PLMHPs, and provisionally licensed therapists completing psychotherapy intake assessments. Use this guide to establish medical necessity, gather clinical information, assess risk, develop a diagnosis, and create the initial treatment plan.
```
90791
Psychotherapy intake
Treatment planning
Risk assessment
Telehealth ready
```
```
```
Assessment Goals
What the therapist should accomplish during the IDI.
- Identify presenting concerns and symptoms.
- Assess functional impairment and medical necessity.
- Develop an initial diagnosis.
- Evaluate safety and risk factors.
- Create an initial treatment plan.
- Determine recommended frequency of treatment.
Presenting Problem
Start broad and understand why they are seeking care now.
- What brings you to therapy today?
- Why are you seeking treatment now?
- How long has this been a concern?
- What would you like help with?
- What would success in therapy look like?
Document symptom duration, severity, frequency, and client goals.
Symptom Assessment
Gather enough information to support diagnosis and treatment need.
- Depression: mood, sleep, appetite, motivation, concentration, hopelessness.
- Anxiety: excessive worry, panic attacks, restlessness, physical symptoms.
- Trauma: nightmares, flashbacks, avoidance, hypervigilance.
- ADHD: focus, organization, impulsivity, task completion.
- Screen for OCD, mania/hypomania, psychosis, anger, grief, and eating concerns.
Functional Impairment
Medical necessity depends on how symptoms impact life.
- How are symptoms affecting work or school?
- How are symptoms affecting relationships?
- How are symptoms affecting parenting or family life?
- How are symptoms affecting daily responsibilities?
- How are symptoms affecting self-care?
Example: Anxiety is causing avoidance, missed work tasks, and conflict in relationships.
Clinical History
Review mental health, medical, medication, and substance history.
- Previous therapy, diagnoses, hospitalizations, or crisis services.
- Current medical conditions, surgeries, head injuries, and sleep concerns.
- Current and past psychiatric medications, effectiveness, and side effects.
- Alcohol, marijuana, nicotine, prescription misuse, and other substance use.
Family, Social & Trauma History
Understand the client’s environment, supports, and stressors.
- Family mental health and substance use history.
- Living situation, relationship status, employment, education, and legal concerns.
- Financial stressors, cultural/spiritual factors, and support system.
- History of abuse, neglect, violence, losses, accidents, or other trauma.
Risk Assessment Required
Every 90791 should include clear SI/HI and safety documentation.
- Suicidal thoughts, plan, means, and intent.
- History of suicide attempts.
- Self-harm history or current urges.
- Homicidal thoughts, plan, means, and intent.
- Protective factors and safety plan when indicated.
If acute risk is present, document your clinical rationale, safety steps, and higher level of care recommendation.
Mental Status Exam
Document observable clinical presentation during the assessment.
- Appearance and behavior.
- Mood and affect.
- Speech.
- Thought process and thought content.
- Orientation.
- Insight and judgment.
Diagnostic Formulation & Medical Necessity
The note should clearly show why therapy is clinically needed now.
- Identify symptoms supporting the diagnosis.
- Consider differential diagnoses and rule-outs when appropriate.
- Document primary diagnosis.
- Clearly connect symptoms to functional impairment.
Medical necessity reminder: The note should answer, “Why does this client require behavioral health treatment at this time?”
Initial Treatment Plan Required
A 90791 should include a preliminary treatment plan, not just a diagnosis.
- Primary problem(s) identified.
- Long-term treatment goal.
- Short-term objectives.
- Recommended interventions.
- Treatment frequency recommendation.
- Estimated duration of treatment.
Example:
Problem: Anxiety impacting work performance and relationships.
Goal: Reduce anxiety symptoms and improve daily functioning.
Objectives: Learn coping skills, improve emotional regulation, reduce avoidance behaviors.
Interventions: CBT, ACT, Supportive Therapy.
Frequency: Weekly psychotherapy sessions.
Problem: Anxiety impacting work performance and relationships.
Goal: Reduce anxiety symptoms and improve daily functioning.
Objectives: Learn coping skills, improve emotional regulation, reduce avoidance behaviors.
Interventions: CBT, ACT, Supportive Therapy.
Frequency: Weekly psychotherapy sessions.
Telehealth Documentation
Use when the 90791 is completed by audio/video telehealth.
- Patient consented to telehealth.
- Patient location documented.
- Therapist location documented.
- Audio/video connection verified.
- Emergency contact information verified.
Example: This assessment was conducted via secure audio/video telehealth. Patient was located in Nebraska and therapist was located in Nebraska. Patient consented to telehealth services.
In-Person Documentation
Use when the client is seen in the office.
- Document that the visit occurred in person.
- Complete the same full clinical assessment.
- No telehealth consent statement is needed.
- Still document risk, MSE, diagnosis, and treatment plan.
Time Documentation Best Practice
90791 is not strictly time-based, but documenting time supports audit readiness.
- Total time spent completing diagnostic assessment.
- Risk assessment.
- Treatment planning.
- Documentation and care coordination.
Example: Total time spent completing diagnostic assessment, risk evaluation, treatment planning, documentation, and coordination of care: 65 minutes.
90791 Minimum Documentation Checklist
Therapists should review this before signing the IDI note.
☑ Presenting problem
☑ Symptom assessment
☑ Functional impairment
☑ Mental health history
☑ Medical history
☑ Medication review
☑ Substance use assessment
☑ Family history
☑ Social history
☑ Trauma history
☑ Strengths and protective factors
☑ Suicide and homicide risk assessment
☑ Mental status exam
☑ Diagnosis
☑ Medical necessity statement
☑ Initial treatment plan
☑ Treatment frequency recommendation
☑ Telehealth documentation, if applicable
☑ Follow-up recommendation