Sheet 1
Psychiatric Diagnostic Procedures
CPT Code
Descriptor
Healthcare Professional
Documentation Requirements
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 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
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
90837
Psychotherapy, 60 minutes with patient
MD, PA, RN, LCSW/LMSW
90845
Psychoanalysis
MD
90846
Family psychotherapy (without the patient present), 50 minutes
MD, PA, RN, LCSW/LMSW
90847
Family psychotherapy (conjoint psychotherapy) (with patient present), 50 minutes
MD, PA, RN, LCSW/LMSW
90849
Multiple-family group psychotherapy
MD, PA, RN, LCSW/LMSW
90853
Group psychotherapy (other than of a multiple-family group)
MD, PA, RN, LCSW/LMSW
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
Psychiatric Diagnostic Procedures
CPT Code
90791
Descriptor
Psychiatric diagnostic evaluation
Healthcare Professional
MD, NPP, LMSW, LCSW, Licensed Psychologist, RN, LMHC, LMFT, LCAT
Documentation Requirements
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
CPT Code
90792
Descriptor
Psychiatric diagnostic evaluation with medical services
Healthcare Professional
MD, NPP
Documentation Requirements
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
Psychotherapy
CPT Code
90832
Descriptor
Psychotherapy, 30 minutes with patient
Healthcare Professional
MD, PA, RN, LCSW/LMSW
Documentation Requirements
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.
CPT Code
90834
Descriptor
Psychotherapy, 45 minutes with patient
Healthcare Professional
MD, PA, RN, LCSW/LMSW
Documentation Requirements
CPT Code
90837
Descriptor
Psychotherapy, 60 minutes with patient
Healthcare Professional
MD, PA, RN, LCSW/LMSW
Documentation Requirements
CPT Code
90845
Descriptor
Psychoanalysis
Healthcare Professional
MD
Documentation Requirements
CPT Code
90846
Descriptor
Family psychotherapy (without the patient present), 50 minutes
Healthcare Professional
MD, PA, RN, LCSW/LMSW
Documentation Requirements
CPT Code
90847
Descriptor
Family psychotherapy (conjoint psychotherapy) (with patient present), 50 minutes
Healthcare Professional
MD, PA, RN, LCSW/LMSW
Documentation Requirements
CPT Code
90849
Descriptor
Multiple-family group psychotherapy
Healthcare Professional
MD, PA, RN, LCSW/LMSW
Documentation Requirements
CPT Code
90853
Descriptor
Group psychotherapy (other than of a multiple-family group)
Healthcare Professional
MD, PA, RN, LCSW/LMSW
Documentation Requirements
Psychotherapy for Crisis
CPT Code
90839
Descriptor
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.
Healthcare Professional
MD, LPC, PsyD PHD, LCSW/LMSW
Documentation Requirements
CPT Code
90840
Descriptor
Psychotherapy for crisis; each additional 30 minutes (list separately in addition to code for primary service).
Healthcare Professional
MD, PA, RN, LCSW/LMFT
Documentation Requirements
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
CPT Code
Total Duration
90832
16-37 minutes
90834
38-52 minutes
90837
> 53 minutes
90846, 90847
> 26 minutes
