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A psychiatric diagnostic evaluation is the comprehensive initial assessment that establishes a mental health diagnosis and treatment plan: psychiatric, medical, family, and social history, a mental status exam, and a risk assessment. Psychiatrists, psychologists, therapists, and psychiatric nurse practitioners complete one at the start of care; US payers bill it as CPT 90791, or 90792 when medical services are included. A typical evaluation runs 500 to 1,200 words.
Psychiatrists, psychiatric NPs and PAs, psychologists, therapists, counselors, clinical social workers
Treating clinician, treatment team, payers, auditors, referral sources
500 to 1,200 words · 30 to 60 minutes by hand (clinical team estimate)
Structured diagnostic assessment (compare: intake note, biopsychosocial assessment)
At the start of care, or when a new episode or a significant change requires reassessment
No law prescribes one form; US Medicare contractor policies list expected elements (90791/90792), and Australia's MBS item 291 codifies its own assessment pathway
A psychiatric diagnostic evaluation is the comprehensive assessment that opens an episode of mental health care: it establishes the diagnosis, the medical necessity for treatment, and the initial plan. Medicare contractor policy describes the service as an "integrated biopsychosocial assessment": a complete medical, psychiatric, family, and social history, a full mental status exam, a tentative diagnosis, and an evaluation of the patient's ability and willingness to participate in the proposed treatment. Clinicians and payers also call it an initial psychiatric evaluation, a diagnostic assessment, a psychiatric intake, or simply a psych eval; one Medicare contractor shortens it to PDE. The current structure dates to January 1, 2013, when the CPT restructure split the older diagnostic interview code 90801 into two services, 90791 without medical services and 90792 with them, and moved interactive complexity to the add-on code 90785.
The codes standardize a service, not a form. No US authority publishes a mandatory evaluation template: content expectations come from your Medicare contractor, payer contracts, licensure, and setting, and they genuinely differ. Even the one federal deadline clinicians quote, 60 hours, belongs to a different setting entirely: 42 CFR 482.61(b) applies to Medicare-certified psychiatric hospitals, an inpatient condition of participation, not an office evaluation. Two boundaries keep the record clean. The evaluation is the billable service that a first-session intake note documents when a qualified clinician performs it. And it is not a HIPAA psychotherapy note: diagnoses, symptoms, treatment plans, and test results are ordinary record material that payers can request, while the protected category covers only separately kept process notes.
Every discipline that opens mental health care performs this evaluation, and the split falls on the medical component. Psychologists, therapists, counselors, and clinical social workers furnish it without medical services (90791); psychiatrists, psychiatric nurse practitioners, and physician assistants can add prescribing, examination, and laboratory work (90792). Medicare has paid marriage and family therapists and mental health counselors directly for it since January 2024. Settings run from private practice and community mental health to hospital outpatient departments, integrated primary care, and telehealth. The evaluation belongs at the start of care, and again when something changes the diagnostic question: a new episode after a gap in treatment, an admission, or a referral that asks something new. Once treatment is underway it hands off to the psychotherapy progress note, and when a focused question surfaces it feeds deeper workups such as the trauma assessment or a full case formulation.
No single form is mandated anywhere. The sections below are the elements Medicare contractor policies list and reviewers across the US, Canada, and Australia expect to find, each with the pitfall that most often undermines it.
Identification and referral. Who the patient is, who referred them and why, and the chief complaint in the patient's own words. Pitfall: paraphrasing the complaint into clinician language; the patient's words anchor medical necessity.
History of present illness. Onset, duration, course, severity, and what the symptoms prevent the patient from doing. Pitfall: symptoms listed without how long they have existed; contractor policy expects the length of existence of the problems.
Past psychiatric history. Prior diagnoses, treatment episodes, hospitalizations, medication trials and response, and past suicide attempts or self-harm. Pitfall: skipping treatment response; the next clinician repeats what already failed.
Medical history and current medications. Significant medical conditions, current medications with doses, and allergies, from every evaluator. Pitfall: therapists and psychologists leaving this section out because they do not prescribe; the expected-element list applies to the evaluation, not the credential.
Substance use. Current and past use, amounts, route, last use, and prior treatment. Pitfall: a bare "denies substance use" with no substances named; an unspecified denial reads as an unasked question.
Family and social history. Psychiatric conditions in the family; living situation, relationships, work or school, legal issues, and stressors. Pitfall: "noncontributory" one-liners; an absence with no content reads as not assessed.
Mental status exam. Appearance, behavior, speech, mood, affect, thought process, thought content, perception, cognition, insight, and judgment. Pitfall: "MSE within normal limits" with no elements; a complete mental status exam is a listed element of the service, and its absence leaves the diagnosis unsupported.
Risk assessment. Suicidal and homicidal ideation, self-harm, access to means, protective factors, and the response when risk is present. Pitfall: no explicit line when risk is negative; the record must show risk was assessed, not assumed absent.
Strengths and liabilities. What the patient brings to treatment, such as supports, insight, and motivation, and what works against it. Pitfall: the element clinicians skip most; it appears on contractor expected-element lists and it is what makes the plan realistic.
Diagnostic impression and treatment plan. The DSM-5-TR diagnosis with its ICD-10-CM code, rule-outs, and a plan with treatment methods, anticipated length where possible, measurable goals, and the patient's ability and willingness to participate. Pitfall: a diagnosis the documented findings do not support, or a plan with no measurable goals; either one breaks the medical-necessity chain every later session relies on.
Patient: [initials] DOB/Age: Date: Clinician: Evaluation type: [90791 / 90792] Referral source & reason: Chief complaint (patient's words): History of present illness (onset / duration / course / severity / impact): Past psychiatric history (dx, treatment & response, hospitalizations, past SI or self-harm): Medical history & current medications (+ allergies): Substance use (current / past / last use / prior treatment): Family history (psychiatric & relevant medical): Social history (living situation / work or school / relationships / legal / stressors): Mental status exam: Appearance & behavior: Speech: Mood & affect: Thought process: Thought content: Perception: Cognition: Insight / judgment: Risk assessment (SI / HI / self-harm / access to means / protective factors): Strengths & liabilities: Diagnostic impression (DSM-5-TR / ICD-10-CM + rule-outs): Treatment plan (methods / frequency / anticipated length / measurable goals / referrals or labs): Patient's ability & willingness to participate: Clinician signature / credentials: Date signed:
Free to use and share, no signup. The PDF includes a one-page cheat sheet with section-by-section pitfalls and a pre-sign checklist; the DOCX is the blank template, ready to adapt.
Scenario: adult client self-referred after a primary care visit, with three months of low mood and worry following a job loss; a licensed psychologist completes the evaluation (90791). All details are fictional.
Patient: D.M., 33 · Date: 07/10/2026 · Type: Psychiatric diagnostic evaluation (90791) · Clinician: A. Reyes, PhD · Referral: self, after primary care visit
Chief complaint: "I lost my job in April and I have not felt like myself since."
History of present illness: About three months of depressed mood, loss of interest, initial insomnia, low energy, and concentration problems after a layoff in April 2026, with worry most days about finances and the job search. Symptoms are present most days and worse in the evenings; client has stopped going to the gym and withdrawn from friends. Passive thoughts of "what's the point" without intent. PHQ-9 today: 16 (moderately severe). GAD-7: 11 (moderate).
Past psychiatric history: One prior depressive episode at age 21, treated with about ten sessions of CBT through college counseling, remitted. No psychiatric medications, no hospitalizations, no prior suicide attempts or self-harm.
Medical history and current medications: Hypothyroidism, on levothyroxine 75 mcg daily; last TSH reported normal (02/2026). No other medications. No known drug allergies.
Substance use: Alcohol two to three drinks per week without binge episodes. Denies tobacco, cannabis, and other drug use. No prior substance use treatment.
Family history: Mother treated for depression. No known family history of suicide, bipolar disorder, or psychosis.
Social history: Lives with partner; laid off from a logistics coordinator role in April 2026; bachelor's degree; no legal involvement. Primary stressor is financial strain. Supportive partner and one close friend.
Mental status exam: Casually dressed with adequate grooming; cooperative. Speech normal in rate and volume. Mood "down"; affect constricted and congruent. Thought process linear and goal-directed. No delusions. Passive death wish without plan or intent; no hallucinations. Alert and oriented x4; attention and memory grossly intact. Insight good; judgment intact.
Risk assessment: Passive ideation without plan, intent, or preparatory behavior; no access-to-means concerns raised. Denies homicidal ideation. Protective factors: supportive partner, treatment-seeking, future orientation with interviews scheduled. Risk judged low; safety discussion completed and documented; will reassess at each session.
Strengths and liabilities: Psychologically minded, prior good response to CBT, stable housing and relationship. Working against treatment: financial stress, reduced activity, thin current social contact.
Diagnostic impression: Major depressive disorder, recurrent, moderate (F33.1); rule out generalized anxiety disorder, with GAD-7 monitoring. The documented duration, prior episode, and functional impact support the diagnosis.
Treatment plan: Weekly individual CBT with behavioral activation, 12 to 16 sessions anticipated. Goals: (1) PHQ-9 below 10 by session 8; (2) three scheduled activity blocks per week by session 4; (3) one social contact re-engaged per week by session 6. Re-administer PHQ-9 and GAD-7 every four weeks. Coordinate with the primary care physician on thyroid monitoring and discuss medication options if the PHQ-9 has not improved by session 8. Next appointment 07/17/2026.
Participation: Patient understands the diagnosis and plan and is willing and able to participate in weekly therapy.
This sample is fictional and for educational purposes. It does not describe a real patient.
Writing these after every session? BastionGPT drafts complete notes from bullets, dictation, or a transcript.
Generate a note from bulletsThe evaluation sits in the designated record set: the patient can request it, payers can audit it, and every later note builds on it. Despite the specialty, it is not a protected HIPAA psychotherapy note; keep private process reflections in separately stored psychotherapy notes and write the evaluation knowing other clinicians, the patient, and reviewers will read it. On timing, there is no national 24-, 48-, or 72-hour completion rule for an outpatient evaluation: Medicare expects documentation at the time of service and accepts a late addition only when it is clearly marked as a delayed entry with its author and date (Program Integrity Manual, chapter 3). Retention is state and provincial law, not HIPAA: HHS states plainly that the Privacy Rule sets no medical-record retention period, while records supporting Medicare billing carry a seven-year duty of their own (42 CFR 424.516(f)).
On the payer side, the evaluation opens the medical-necessity chain that every later claim leans on, and the sharpest rules are the ones template pages rarely state. Frequency is contractor policy, not a national rule, and the contractors genuinely differ: First Coast covers the evaluation once at the onset of an illness and again after roughly a six-month treatment hiatus, an inpatient admission, or a marked change; Novitas policy recognizes initial and periodic evaluations, notes that children and geriatric patients may need more than one visit to complete one, and caps coverage at three per year per beneficiary by the same provider; Noridian allows one per day, permits more than one per year with a separate evaluation, and adds two hard lines: never billed incident-to, and never on the same day as an E/M visit. Nationally, the 2026 NCCI manual bundles the evaluation with psychotherapy on the same date because "psychotherapy includes continuing psychiatric evaluation." The 90792 version needs documented medical work, such as examination elements, prescriptions, or labs, and the interactive complexity add-on 90785 needs a documented communication factor from the APA and AACAP guidance, not just a young patient or family in the room. Two current openings are worth knowing: the evaluation can serve as the initiating visit for principal illness navigation services, and it remains billable by telehealth, including from the patient's home, under flexibilities that run through December 31, 2027.
The best public number is category-level, and it is not small: for the 2024 reporting period, Medicare's improper-payment rate for outpatient psychiatry was 16.1%, a projected $254.5 million, with insufficient documentation driving 78.3% of the improper payments and missing documentation another 17%. No published denial rate exists for 90791 or 90792 specifically, and pages that quote one are inventing it. The BastionGPT Clinical Advisory Board sees the same errors most often in psychiatric diagnostic evaluation reviews:
| Aspect | United States | Canada | Australia |
|---|---|---|---|
| Status | No law mandates a form; CPT defines the service (90791/90792), Medicare contractor policies list expected elements and frequency, and national coding policy bundles same-day psychotherapy and E/M | No national billing code or form exists; provincial fee schedules pay psychiatrist assessments and provincial colleges prescribe record content, with Quebec regulating psychologists' records by law | MBS item 291 is a statutory pathway: a referred psychiatrist assessment over 45 minutes with a mental state examination, an outcome tool when appropriate, and a defined report-back; item 296 covers ordinary initial consultations |
| Terminology | Psychiatric diagnostic evaluation, initial psychiatric evaluation, diagnostic assessment, 90791/90792, PDE | Initial psychiatric assessment, psychiatric consultation, comprehensive psychiatric assessment, diagnostic assessment | Initial psychiatric consultation, comprehensive diagnostic assessment, assessment and management plan (item 291) |
| What changes | Which contractor's rules apply: First Coast covers one evaluation per illness with defined repeat triggers, Novitas caps three per year, Noridian bars incident-to billing | Which province and college govern: record content, supervision co-signature rules, and retention all vary by regulator | The report-back obligation: item 291 requires a written report to the referrer within two weeks containing the diagnostic assessment and a 12-month biopsychosocial management plan, and cannot repeat within 12 months |
| Retention | HIPAA sets no chart period; state law governs, and records supporting Medicare claims carry seven years (42 CFR 424.516(f)) | Quebec sets five years by regulation, Ontario colleges use ten years or age 18 plus ten, and BC's harmonized standard runs 16 years | Psychology Board code: seven years from last entry for adults, and past the 25th birthday for clients seen as minors; doctors follow state law |
The clinical skeleton, history, mental status exam, diagnosis, and plan, travels across all three countries. What changes is the surrounding machinery: a US contractor decides how often the service is payable, a Canadian college decides what the record must contain and for how long, and the Australian schedule turns one version of the assessment into a statutory report with a deadline.
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90791 is the psychiatric diagnostic evaluation without medical services; 90792 includes them: clinically indicated examination elements, prescription work, and ordering or reviewing labs. Psychologists, therapists, counselors, and clinical social workers bill 90791. Physicians, psychiatric NPs, and PAs choose between 90792 and an E/M visit for the same encounter, and the medical work has to appear in the note either way. Medicare coding policy does not allow a separate E/M charge alongside either code on the same day.
There is no national once-a-year rule; frequency is Medicare contractor policy, and the contractors differ. First Coast covers one evaluation at the onset of an illness, with repeats after roughly a six-month treatment hiatus, an inpatient admission, or a significant change. Novitas policy recognizes initial and periodic evaluations for a new episode, a readmission, or a new referral question, and caps coverage at three per year per beneficiary by the same provider. Noridian allows one per day and more than one per year when each is a separate, medically necessary evaluation. If one evaluation takes two visits, which Novitas notes can happen with children and geriatric patients, it is still one service, not two.
90791 and 90792 are not time-based codes: no national rule sets a minimum duration, a required 60 minutes, or a 16-to-90-minute window, despite what many template pages claim. Most clinicians block 45 to 90 minutes as a practical matter, and writing the note takes 30 to 60 minutes by hand (our clinical team's estimate; no published time study exists). The only federal completion deadline belongs to another setting: Medicare-certified psychiatric hospitals must complete the inpatient psychiatric evaluation within 60 hours of admission under 42 CFR 482.61(b). That rule does not apply to an office evaluation.
Not to Medicare. The 2026 NCCI policy manual states that "psychotherapy includes continuing psychiatric evaluation," so 90791 and 90792 are not separately reportable with individual, group, family, crisis, or other psychotherapy on the same date. The same manual bars a separate E/M code with either evaluation code, and contractor policy excludes same-day crisis psychotherapy as well. If therapy genuinely begins the same day, the evaluation code carries the encounter; psychotherapy billing starts at the next visit.
Under Medicare: physicians, clinical psychologists, clinical social workers, clinical nurse specialists, NPs, PAs, and, since January 1, 2024, independently enrolled marriage and family therapists and mental health counselors. Payment differs by credential for the same service: physicians and clinical psychologists receive 100% of the fee schedule amount, while CSWs, MFTs, and MHCs receive 75% of the clinical psychologist rate. Noridian adds a rule many practices miss: the evaluation is never billed incident-to. 90792 requires a clinician qualified to furnish the medical work.
No. DSM-5 retired the multiaxial system and the GAF score in 2013; the APA's own insurance guidance recommends separate severity and disability measures, with WHODAS 2.0 as the disability instrument. Some Medicare contractor policies still carry pre-2013 wording, such as "multi-axis diagnosis or diagnostic impression list": the second half of that phrase is the operative one. A single-axis DSM-5-TR diagnosis with its ICD-10-CM code, plus Z-codes for psychosocial factors, satisfies the intent. If a specific payer form still demands a GAF, that is the payer's requirement, not the DSM's.
The psychiatric diagnostic evaluation is a billable service with payer-defined expectations. The intake note is the practice document that records a first session, and it supports the evaluation code when a qualified clinician actually performs the diagnostic work. A biopsychosocial assessment is a content framework covering biological, psychological, and social domains; it can supply most of an evaluation's content but is not itself a separate billable service. When standardized testing is needed, that is a different service family entirely, documented in a psychological evaluation report.
Yes. 90791 and 90792 are on the Medicare telehealth list, and current flexibilities, extended through December 31, 2027, allow the patient to be at home. Video is the default; audio-only is billable with modifier 93 when the patient cannot or will not use video, and home-based services use place-of-service 10. Document the modality, the patient's location, and consent the same way you would for a telehealth therapy session. State licensure and payer-specific telehealth rules still apply.
Yes. Give it your interview notes, a dictation, or a session transcript, and it drafts the full evaluation for your review: histories, mental status exam, risk statement, diagnostic impression, and a plan with measurable goals. It can also check a finished draft for the gaps auditors flag, like a missing MSE element or an unsupported diagnosis. BastionGPT is HIPAA-compliant with a signed BAA on every plan, and your data is never used to train models.
The compliance and payer claims on this page trace to these authorities, last verified July 2026:
Educational content, not legal or billing advice. Sample notes are fictional. Follow your organization's policies and your board, payer, and jurisdiction requirements.