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CPT Code 90791 Documentation Requirements: Complete Checklist Required Documentation Elements for Compliant 90791 Billing Complete documentation for CPT Code 90791 must include all of the following to support medical necessity and withstand a payer audit: Chief complaint and presenting problem History of present illness: onset, duration, severity, and exacerbating or alleviating factors Complete psychiatric history: prior diagnoses, hospitalizations, and treatment history Relevant medical history pertaining to the psychiatric differential Substance use history: substances, frequency, and last use Family psychiatric and medical history Psychosocial and developmental history Mental Status Examination with all domains documented Narrative risk assessment with clinical reasoning: suicidal and homicidal ideation, self-harm, and safety concerns DSM-5 or ICD-10 diagnostic impression with supporting rationale Initial treatment plan: modality, frequency, approach, and measurable goals Missing even one of these elements, particularly the risk assessment or the treatment plan, is a leading cause of 90791 claim denials and audit recoupments

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