Psychotherapy Medical Billing & Coding Guide for 2024

Psychotherapy Medical Billing & Coding Guide for 2021

During these difficult and uncertain times, psychotherapy and mental health services are more important and more in-demand than ever.

As such, psychotherapy medical billing guidelines are also more important than ever.

Whether you are a psychiatrist (MD), licensed clinical social worker (LCSW), clinical psychologist (PsyD or PhD), or licensed professional counselor (LPC), CPT codes are how mental health professionals across the country get paid for their essential work.

Is your practice considering adding an additional office location or providing teletherapy services?

Will your EMR allow you to stay HIPAA compliant while incorporating Centers for Medicare and Medicaid Services changes in behavioral health guidelines?

If so, it is crucial that your practice stays up to date on current changes in psychotherapy medical billing and coding. 

Psychotherapy Medical Billing & Coding Guide for 2021

Psychotherapy Medical Billing & Coding Guide for 2024

Neolytix has compiled this psychotherapy medical billing 101-guide to help mental health practices everywhere get up to speed with the new rules. This guide was written by our expert team of medical billers and coders. It examines core topics of psychotherapy medical billing and coding such as:

  • The different types of CPT codes used in psychotherapy medical billing
  • The definitions and requirements for each code
  • Which healthcare providers bill for which codes
  • Applicable modifiers for codes
  • Rules of proper documentation

Psychotherapy notes are kept confidential and excluded from an individual’s right under HIPAA to access protected health information. However, the healthcare professional must maintain adequate documentation for each encounter.

As a growing mental health practice, your success hinges on understanding the ins and outs of psychotherapy medical billing. 

This guide will show you how to do just that. It is based on ICD-10-CM, which took effect in October of 2023 and will apply for calendar year 2024.

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Table of Contents

Commonly Used CPT Codes in Psychotherapy Medical Billing

There are many CPT codes currently used by mental health professional that can be reported under the following categories:

  1. Health Behavior Assessment and Intervention (CPT codes 96156-96171)
  2. Psychotherapy Codes (CPT codes 90832-90863)
  3. Psychological and Neuropsychological Testing Codes (CPT codes 96105-96146)

Listed below are the most common psychotherapy CPT codes, as well as which healthcare professionals can report which codes.

This is not a comprehensive list of CPT codes. It is simply a general description of commonly performed mental health services.

CPT Code
Descriptor
Healthcare Professional
Documentation Requirements

Psychiatric Diagnostic Procedures

90791

Psychiatric diagnostic evaluation

MD, NPP, LMSW, LCSW, Licensed Psychologist, RN, LMHC, LMFT, LCAT

  • Elicitation of a complete medical and psychiatric history (including past, family, social)

  • Mental status examination

  • Establishment of an initial diagnosis

  • Evaluation of the patient’s ability and capacity to respond to treatment

  • Initial plan of treatment

  • Reported once per day and NOT on the same day as an E/M service performed by the same individual for the same patient

  • Covered once at the outset of an illness or suspected illness

90792

Psychiatric diagnostic evaluation with medical services

MD, NPP

  • Elicitation of a complete medical and psychiatric history (including past, family, social)

  • Mental status examination

  • Establishment of an initial diagnosis

  • Evaluation of the patient’s ability and capacity to respond to treatment’

  • Initial plan of treatment

  • Reported once per day and ON the same day as an E/M service performed by the same individual for the same patient

  • Covered once at the outset of an illness or suspected illness

Interactive Complexity

CPT Code
Descriptor
Healthcare Professional
Documentation Requirements

90875

Interactive Complexity add-on code

MD/DO, PSY, CNSCNP, PA, LISW, LIMFT, LPCC, LSW, LMFT, LPC

Include 90785 in addition to the primary procedure, when at least one of the following communication factors is present and documented during the visit:

  • The need to manage maladaptive communication (related to, e.g., high anxiety, high reactivity, repeated questions, or disagreement) among participants that complicates delivery of care.

  • Caregiver emotions or behaviors that interfere with implementation of the treatment plan.

  • Evidence or disclosure of a sentinel event and mandated report to a third party (e.g., abuse or neglect with report to state agency) with initiation of discussion of the sentinel event and/or report with patient and other visit participants.

  • Use of play equipment, physical devices, interpreter or translator to overcome barriers to diagnostic or therapeutic interaction with a patient who is not fluent in the same language or who has not developed or lost expressive or receptive language skills to use or understand typical language.

Psychotherapy

CPT Code
Descriptor
Healthcare Professional
Documentation Requirements

90832

Psychotherapy, 30 minutes with patient

MD, PA, RN, LCSW/LMSW

Documentation to support psychotherapy should include, but is not limited to the following:

  • Time element as noted above

  • Modalities and frequency

  • Clinical notes for each encounter that summarizes the following:

    • Diagnosis

    • Symptoms

    • Functional status

    • Focused mental status examination

    • Treatment plan, prognosis, and progress

    • Name, signature and credentials of person performing the service.

Documentation must support a face to face service. While it may include the involvement of family members, the patient MUST be present for all or some of the time. See CPT code 90846 for family visits without patient present.

90834

Psychotherapy, 45 minutes with patient

MD, PA, RN, LCSW/LMSW

Psychotherapy documentation as stated in 90832.

90837

Psychotherapy, 60 minutes with patient

MD, PA, RN, LCSW/LMSW

Psychotherapy documentation as stated in 90832.

90845

Psychoanalysis

MD

Psychiatric diagnostic evaluation is an integrated biopsychosocial assessment, including history, mental status, and recommendations. The evaluation may include communication with family or other sources and review and ordering of diagnostic studies.

90846

Family psychotherapy (without the patient present), 50 minutes

MD, PA, RN, LCSW/LMSW

Psychotherapy documentation as stated in 90832.

90847

Family psychotherapy (conjoint psychotherapy) (with patient present), 50 minutes

MD, PA, RN, LCSW/LMSW

Psychotherapy documenation in addition to treatment strategy used to modifiy family behavior and attitudes.

90849

Multiple-family group psychotherapy

MD, PA, RN, LCSW/LMSW

Psychotherapy documenation in addition to treatment strategy used to modifiy family behavior and attitudes.

90853

Group psychotherapy (other than of a multiple-family group)

MD, PA, RN, LCSW/LMSW

  • Groups designed to target specific problem; depression, obesity, panic disorder, social anxiety (anger, shyness, loneliness, low self-esteem), loss of family member, chronic pain or substance abuse.

  • Does not include recreational activities, play, eating together, art or music therapy, excursions, sensory stimulation, socialization, motion therapy, etc.

  • The code is used to report per-session services for each group member.

Psychotherapy for Crisis

CPT Code
Descriptor
Healthcare Professional
Documentation Requirements

90839

Psychotherapy for crisis; first 60 minutes

*Billed for the first 60 mins of psychotherapy for a patient in crisis, and add-on code 90840 billed for each additional 30 mins.

MD, LPC, PsyD PHD, LCSW/LMSW

90840

Psychotherapy for crisis; each additional 30 minutes (list separately in addition to code for primary service).

MD, PA, RN, LCSW/LMFT

  • A preliminary assessment of risk, mental status, and medical stability

  • The need for further evaluation or referral to other mental health services (if applicable)

  • Communication with contacts who may have pertinent information for the assessment

  • Substance use (if applicable)

  • Outcome of the session

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When to Use Psychotherapy CPT Codes

The U.S. Department of Health and Human Services defines psychotherapy as:

The treatment of mental illness and behavioral disturbances in which the physician or other qualified health care professional, through definitive therapeutic communication, attempts to alleviate the emotional disturbances, revere, or change maladaptive patterns of behavior, and encourage personality growth and development.

As such, individual psychotherapy CPT codes should be used only when the focus of treatment involves individual psychotherapy.

Psychotherapy CPT codes should not be used when other CPT codes are more appropriate. For example, for some services an evaluation and management (E/M) or pharmacological code may be more fitting.

Important! All psychotherapy CPT codes are time-based. The time for a psychotherapy code is defined as the time spent with the patient and/or patient’s family.

While time for each code is specified in increments of 30, 45, or 60 minutes, the coding manual allows for some flexibility. Luckily, the American Academy of Child & Adolescent Psychiatry (AACAP) has developed a rule for recording time accurately when it does not match the exact time increments specified in the CPT code. The rule is:

CPT Code
Total Duration

90832

16-37 minutes

90834

38-52 minutes

90837

> 53 minutes

90846, 90847

> 26 minutes

All mental health professionals who deliver psychotherapy services, including psychologists, psychiatrists, nurses, and social workers, use the same applicable CPT codes.

They use them when billing clients and when filing CMS-1500 claim forms with third-party payers such as Medicare, Medicaid, and private health insurance carriers.

Finally, what is the difference between report E/M CPT codes and psychotherapy CPT codes? The following table explains the key distinctions:

Psychotherapy

90833

Psychotherapy, 30 minutes with patient with E/M

MD

Documentation to support psychotherapy should include, but is not limited to the following:

  • Time element as noted above

  • Modalities and frequency

  • Clinical notes for each encounter that summarizes the following

    • Diagnosis

    • Symptoms

    • Functional status

    • Focused mental status examination

    • Treatment plan, prognosis, and progress

    • Name, signature and credentials of person performing the service

Documentation must support a face to face service. While it may include the involvement of family members, the patient MUST be present for all or some of the time. See CPT code 90846 for family visits without patient present.

90836

Psychotherapy, 45 minutes with patient with E/M

MD

With an Evaluation and Management (E/M) code with an appropriate history, physicial examination with Medical Decision Making of Straightforward, Low, Moderate and High being the driving factor in E/M code selection.

**Time is not a determining factor when selecting an E/M code with Psychotherapy. Evalaution and Management time is not included in the time for Psychotherapy**

90838

Psychotherapy, 60 minutes with patient with E/M

MD

Are you worried about receiving and validating all the necessary info for your psychotherapy services on time? Consider these custom online fillable forms from Practice Tech Solutions.

Group psychotherapy for men with different problems and issues

Different CPT Codes for Psychotherapy Services Rendered

Each CPT code describes a specific medical, diagnostic, or surgical procedure or service. The AMA created these codes to reflect the service rendered by the provider. In choosing a CPT code, the medical coder must select the code that best reflects the service rendered by the healthcare professional.

Below we look at three CPT codes in detail to better understand the requirements of performing and documenting certain psychotherapy services. 

CPT Code 90791: Psychiatric diagnostic evaluation

Is a mental psychiatric diagnostic evaluation with an integrated biopsychosocial assessment, including history, mental status, and recommendations.

This CPT code is used to describe an initial visit to a new patient or an established patient with a new diagnosis. This visit may include diagnostic assessment or reassessment but not psychotherapy services.

During the encounter, the provider must document:

  • Elicitation of a complete medical and psychiatric history (including past, family, social)
  • Mental status examination
  • Establishment of an initial diagnosis
  • Evaluation of the patient’s ability and capacity to respond to treatment.’
  • Initial plan of treatment
  • Reported once per day and NOT on the same day as an E/M service performed by the same individual for the same patient.
  • Covered once at the outset of an illness or suspected illness (see LCD for exceptions)

 

CPT Code 90832: Psychotherapy; 30 minutes with patient

Psychotherapy is the treatment of mental illness and behavioral disturbances in which the physician or other qualified health care professional, through definitive therapeutic communication, attempts to alleviate the emotional disturbances, reverse, or change maladaptive patterns of behavior, and encourage personality growth and development. Documentation to support psychotherapy should include, but is not limited to the following:

  • Time element as noted above
  • Modalities and frequency

Clinical notes for each encounter that summarizes the following:

  • Diagnosis
  • Symptoms
  • Functional status
  • Focused mental status examination.
  • Treatment plan, prognosis, and progress
  • Name, signature and credentials of person performing the service

 

CPT Code 90839: Psychotherapy for crisis; first 60 minutes + CPT Code 90840 Psychotherapy for crisis; each additional 30 minutes (list separately in addition to code for primary service 90839)

Mental status exam and psychotherapy for crisis is an urgent assessment and history of a crisis state, a mental status exam, and a disposition. The presenting problem is typically life threatening or complex and requires immediate attention to a patient in high distress.

During the encounter, the provider must document: 

  • A 60-minute session with start and stop time (30–74 minutes). 
  • A preliminary assessment of risk, mental status, and medical stability. 
  • Psychotherapy (for crisis of less than 30 minutes total duration on a given date should be reported with 90832 or 90833 when an evaluation and management services) 
  • Mobilization of resources to defuse the crisis and restore safety 
  • The need for further evaluation or referral to other mental health services, if applicable. 
  • Communication with contacts who may have pertinent information for the assessment 
  • Provision of psychotherapeutic intervention to minimize emotional trauma. 
  • Substance use, if applicable. 
  • Outcome of the session.

 

CPT Code 90839 and add-on code 90840 should not be billed in conjunction with these codes:  

90791 (Psychiatric diagnostic evaluation) 

90792 (Psychiatric diagnostic evaluation with medical services) 

90785-90899 (Psychiatric services and procedures) 

90832-90838 (Psychotherapy services and procedures) 

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Incident-To Guidelines in Psychotherapy Medical Billing

It is common for multiple healthcare professionals to work together in providing care for patients. When a non-physician provider furnishes services to a physician professional, incident-to guidelines are used for billing under the provider’s NPI.

According to the Medicare Benefit Policy Manual, incident-to is defined as: 

According to the Final Rule which amends the direct supervision requirement under the incident-to billing regulation to allow behavioral health services to be furnished under the general (instead of direct) supervision of a physician or NPP when these services or supplies are provided by auxiliary personnel (such as such licensed professional counselors (LPCs) and licensed marriage and family therapists (LMFTs)) incident to the services of a physician or NPP.

The physician professional in the medical documentation must clearly note the incident-to guidelines when a non-physician provider performs work. The following information must be included:

  • Documentation entries must have co-signature or legible identity and credentials (i.e., MD, DO, NP, PA, etc.) of both the practitioner who provided the service and the supervising physician. 
  • Some indication of the supervising physician’s involvement with the patient’s care. This indication could be satisfied by:
    • Notation of supervising physician’s involvement within the text of the associated medical record entry. The degree of involvement must be consistent with clinical circumstances of the care.
    • Documentation from other dates of service than those requested (the initial visit, for example). This establishes the link between the two providers. 

Modifiers Used in Psychotherapy Medical Billing

Modifiers are used to show that a medical service or procedure has been altered by some specific circumstance but has not been changed in its definition or code.

Psychotherapy medical billing does not have any modifiers associated with it. However, you should review your insurance carriers to see if they require any local modifiers.

For example, if psychotherapy is conducted via teletherapy, an applicable telemedicine modifier may be required.

Proper Documentation for Psychotherapy Medical Billing

Documentation plays the essential role of explaining the medical necessity of procedures rendered by the provider. All documentation must comply with legal/regulatory requirements of the state in which the provider practices.

According to the Office For Civil Rights HIPPA guidelines for Psychotherapy notes are treated differently from other mental health information both because they contain particularly sensitive information and because they are the personal notes of the therapist that typically are not required or useful for treatment, payment, or health care operations purposes, other than by the mental health professional who created the notes. Therefore, with few exceptions, the Privacy Rule requires a covered entity to obtain a patient’s authorization prior to a disclosure of psychotherapy notes for any reason, including a disclosure for treatment purposes to a health care provider other than the originator of the notes. See 45 CFR 164.508(a)(2). A notable exception exists for disclosures required by other law, such as for mandatory reporting of abuse, and mandatory “duty to warn” situations regarding threats of serious and imminent harm made by the patient (State laws vary as to whether such a warning is mandatory or permissible).

All medical records should include:

  • Date of service and provider information
  • History
  • Observations and type of therapy
  • Diagnoses
  • Medications
  • Progress and follow-up
  • E/M documentation if applicable

If you are a little uncertain about documentation, or just do not have the time, consider hiring a virtual medical assistant. VAs can oversee all sorts of administrative and clerical tasks with expertise and efficiency.

Most Common Reasons for Psychotherapy Claim Denials

  • Incomplete documentation for the behavioral health services rendered.
  • Incorrect patient insurance and coverage: Always verify patient information and coverage. Many times, mental health services are offered by third-party insurance. Thus, it is critical to conduct a verification of benefits yourself. 
  • Incorrect CPT codes: CPT codes change rapidly. Your practice should keep their superbills updated to the most accurate CPT codes set by AMA. 
  • Inaccurate time-based codes: This is another frequent error. If a CPT code is time-based, ensure that the units of service are accurate.
  • Timely filing: Make sure all claims are submitted on time. Missing even one deadline can cause major delays in filing and reimbursement.
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Psychotherapy Medical Billing & Coding Guide for 2021

Conclusion

In conclusion, we hope this guide has helped you and your practice understand the basics of psychotherapy medical billing and coding. No matter your field, all providers must complete the proper medical documentation, explain the medical need for services rendered, and submit clean claims to insurance companies.

If the documentation is clear and well written, billing is easy. Make a habit of keeping up to date on the latest changes in psychotherapy medical billing, and you will save yourself a lot of trouble down the road.

Looking for some quick assistance with your psychotherapy medical billing?

Neolytix offers a full selection of medical billing services. We work with therapists and mental health professionals across the country to optimize their billing processes and boost their cash flow. 

Reach out to us anytime, or complete the from below for a free consultation.

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