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What CPT Code 90791 Includes A complete psychiatric diagnostic evaluation billed under CPT Code 90791 covers the following components: Complete psychiatric and medical history Biopsychosocial assessment Mental status examination (MSE) Risk assessment, including suicidal ideation and safety concerns Diagnostic formulation using DSM-5/ICD-10 criteria Initial treatment plan with specific recommendations Communication with family or collateral sources when clinically appropriate Review of prior records when available CMS expects all of these elements to be present in your documentation

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