Therapists, counselors, and other behavioral health professionals who run their own practice end up wearing many hats: practitioner, small business owner, customer support, marketer, tech support, etc. If you accept insurance, you’re also playing the role of medical coder and that requires you to familiarize yourself with CPT Codes for psychotherapy.
CPT Codes are the five digit codes maintained by the AMA and used to describe medical procedures and services. Using the correct CPT Code (as well as any appropriate add-on codes) for the services provided to your clients will help ensure that insurance companies reimburse the correct amount as quickly as possible. While accepting insurance for mental and behavioral health services can sometimes result in more paperwork and the occasional headache, it’s also key to keeping the out-of-pocket cost of therapy down and ensuring mental healthcare remains accessible to as many people as possible.
Note: ICD10 Codes (Diagnosis Codes) are different than CPT Codes. If you need to look up ICD10 Codes for a diagnosis you can do so here.
Here are some of the most common psychotherapy CPT Codes:
90791: Psychiatric Diagnostic Evaluation (Initial Assessment)
A psychiatric diagnostic evaluation is an integrated biopsychosocial assessment, including client history, mental status, and treatment recommendations. It may include communication with family or other sources and review, and ordering of diagnostic studies.
When to Use Code 90791
This code is typically used for the first session/initial client assessment, and once per year after, at yearly progress evaluations.
When Not to Use Code 90791
This code can typically only be used once per year, per client, at the outset of treatment.
What to Document for Code 90791
- Session start and end time
- Diagnosis
- Symptoms
- Functional status
- Mental Status Examination
- Collection of a complete medical and psychiatric history
- Evaluation the client’s ability and capacity to respond to treatment
- Treatment plan, prognosis, and progress
- Name, signature, and credentials of provider
90834: Individual Psychotherapy for ~45 minutes
Used when providing insight oriented, behavior modifying, supportive, and/or interactive psychotherapy.
When to use Code 90834
For a therapy session 38-52 minutes in length. This length is session face-to-face time, not including any administrative (documentation) time.
When Not to Use Code 90834
Services not to be included in coding insurance claims with 90834 are: Teaching grooming skills and/or Recreational therapy (dance, art, or play)
What to Document for Code 90834
- Session start and end time
- Goal of session
- Interventions used
- Client response to interventions
- Plan for client next steps/continued treatment
- Name, signature, and credentials of provider
90837: Individual Psychotherapy for ~60 minutes
Used when providing insight oriented, behavior modifying, supportive, and/or interactive psychotherapy.
When to Use Code 90837
For a therapy session over 53 minutes in length. This length is session face-to-face time, not including any administrative (documentation) time.
*Please note: The 90837 code is viewed by insurance companies as a non-routine code generally used for clients in acute crisis or in need of stabilization. Example diagnoses may include PTSD, panic disorder, or OCD. Routine and recurring sessions billed with 90837 can be a trigger for an audit by insurers. If you determine that a longer session is necessary to treat your client, the best practice is to include justification as to why in your progress notes.*
When Not to Use Code 90837
Services not to be included in coding insurance claims with 90837 are: Teaching grooming skills, Monitoring daily living activities (ADL), Recreational therapy (dance, art, play), and/or Social interaction
What to Document for Code 90837
- Session start and end time
- Symptoms and severity (*particularly important with 90837)
- Goal of session
- Interventions used
- Client response to interventions
- Progress and what is left to work on (*particularly important with 90837)
- Plan for client next steps/continued treatment
- Name, signature, and credentials of provider
90832: Individual Psychotherapy for ~30 mins
Used when providing insight oriented, behavior modifying, supportive, and/or interactive psychotherapy.
When to Use Code 90832
For a therapy session 17-37 minutes in length. This length is session face-to-face time, not including any administrative (documentation) time.
When Not to Use Code 90832
Services not to be included in coding insurance claims with 90832 are: Teaching grooming skills and/or Recreational therapy (dance, art, or play)
What to Document for Code 90832
- Session start and end time
- Goal of session
- Interventions used
- Client response to interventions
- Plan for client next steps/continued treatment
- Name, signature, and credentials of provider
90847: Family or Couples Therapy with the Patient Present
Used for face-to-face or telehealth couples and family psychotherapy sessions of 26 minutes or longer.
When to Use Code 90847
When the primary purpose of the session is the treatment of the *identified client’s” condition. Examples of this include: When there is a need to observe and correct, through psychotherapeutic techniques, the client’s interaction with partner/family members; When there is a need to assess the conflicts or impairments within the relationship/family, and assist, through psychotherapy, the family members in the management of the client/symptoms. (*Identified Client” = Primary holder of the insurance or the one with the more severe symptoms).
When Not to Use Code 90847
Do not bill 90847 when the service being performed is taking a family history or requesting a brief update on the patient’s behavior prior to or after an individual session. This code also does not cover family counseling/therapy with professional caretakers for, or staff of, the clients.
What to Document for Code 90847
- Session start and end time
- Diagnosis
- Others present and their relationship to the client (*particularly important with 90847)
- Rationale for the need for couples/family treatment (*particularly important with 90847- see “When to use” above for examples)
- Goal of session
- Interventions used
- Client response to interventions
- Plan for client next steps/continued treatment
- Name, signature, and credentials of provider
90839: Psychotherapy for Crisis; first 60 minutes
Used as the principal code for a crisis psychotherapy session requiring urgent assessment and history of the crisis state, mental status exam, and disposition.
When to Use Code 90839
Use code 90839 to bill for the first 60 minutes of psychotherapy with a patient in crisis (*add on code 90840 can be billed for each additional 30 minutes of crisis psychotherapy). This length is session face-to-face time, not including any administrative (documentation) time *Please note: In order to use this code, the presenting problem must typically be life-threatening or complex and require immediate attention to a patient in high distress. It is especially important to document the medical necessity of the situation, the risk, any referrals to other services, and communication with other contacts when billing this code.
When Not to Use Code 90839
Services not to be included in coding insurance claims with 90837 are: Teaching grooming skills, Monitoring daily living activities (ADL), Recreational therapy (dance, art, play), and/or Social interaction
What to Document for Code 90839
- Session start and end time
- Symptoms and severity (*particularly important with 90839)
- Medical necessity of situation (*particularly important with 90839)
- Risk involved in situation (*particularly important with 90839)
- Communication with resources/client contacts (*particularly important with 90839)
- Interventions used
- Client response to interventions
- Plan for client next steps/continued treatment
- Name, signature, and credentials of provider
Common Add-On Codes
Add-on codes are CPT Codes that are listed separately for services that are performed in conjunction with a Primary Service. Add-on codes are only eligible for payment if it accompanies the appropriate Primary Service. If the Primary Service is denied for whatever reason, the add-on code will also be denied.
Here is a list of common add-on codes for psychotherapy:
90840: Psychotherapy for Crisis; each additional 30 minutes
Used if/when a crisis psychotherapy session lasts longer than 60 minutes. The add-on code, 90840, can be billed for each additional 30 minutes of psychotherapy for crisis. List separately in addition to code for primary service.
All documentation requirements of Code 90839 apply to Code 90840.
