Mental Health Billing & Coding Guideline

Understanding how to code for behavioral health services accurately is essential for compliance and ensuring that providers are adequately reimbursed for the care they deliver. 

This guide examines the primary CPT codes utilized in behavioral health, encompassing those for initial evaluations, re-evaluations, psychotherapy, and medication management.

Because coding rules can vary depending on the provider type, we will also clarify what applies to psychiatrists, nurse practitioners (NPs), physician assistants (PAs), clinical psychologists (CP), clinical social workers (CSW, LCSW), independently practicing psychologists (IPP) and other licensed professionals. Explore each section to help you bill confidently and correctly across various behavioral health services.

This detailed guide will answer questions about how to code for the following services:

• Initial evaluations
• Re-evaluations
• Medical management
• Psychotherapy

Psychiatric Diagnostic Evaluation 

There are two codes for psychiatric diagnostic evaluation:

• 90791: Psychiatric diagnostic evaluation 
• 90792: Psychiatric diagnostic evaluation with medical services

Code 90791: Psychiatric Diagnostic Evaluation

Psychiatric diagnostic evaluation is an integrated biopsychosocial assessment, including history, mental status, and recommendations. The evaluation may include communication with family or other source,s and review and ordering diagnostic studies. 90791 is used by psychologists, social workers, and other licensed behavioral health professionals. The evaluation may also involve gathering collateral information from family or caregivers and reviewing previous records. However, it does not include medical services such as prescribing or ordering diagnostic studies.

Code 90792: Psychiatric Diagnostic Evaluation with Medical Services

CPT 90792 is reserved for psychiatric medical providers, including psychiatrists, psychiatric nurse practitioners, and physician assistants. Psychiatric diagnostic evaluation with medical services is an integrated biopsychosocial and medical assessment, including history, mental status, other physical examinations as indicated, and recommendations.. This evaluation encompasses all elements of 90791, including medical components such as reviewing or ordering laboratory tests, conducting physical examinations, and prescribing medication. If medical decision-making is involved, this code is appropriate and more comprehensive.

When and How to Use These Codes

These evaluations are typically performed at the start of treatment or after a significant clinical change, such as following discharge from an inpatient setting. While CPT® does not limit the frequency of these codes, a second evaluation may only be billed when medically necessary, for example, after a lapse in care or when new presenting issues require reassessment. It is important not to report multiple evaluations routinely unless each is documented and justified.

CPT also permits these services to be rendered to someone other than the patient (such as a caregiver) when that individual provides critical clinical information. Furthermore, the evaluation may occur across two sessions—one with the patient and one with a family member—and be billed twice, provided medical necessity and appropriate documentation support both services.

Where the Service Can Be Performed

Both 90791 and 90792 can be performed in various clinical settings, including outpatient offices, inpatient psychiatric units, emergency departments, residential treatment centers, and through telehealth (with the appropriate place of service codes and modifiers). The setting does not determine the code; the scope of services and the provider’s credentials are the key factors.

Documentation Requirements

Documentation must reflect a complete and clinically justified assessment to support billing for either code. It should include the date and location of service, presenting concerns, mental status findings, clinical impressions, and a treatment plan. If 90792 is billed, medical decision-making, any prescriptions issued, and relevant physical assessment details must also be documented. While not always required, documenting start and stop times is recommended for compliance and defense against audits.

Coding Tip: 90792 or Standard E/M? Know the Right Choice.

When reporting an assessment of a patient, although your psychiatrist is allowed to use both E/M services as well as 90792 (Psychiatric diagnostic evaluation with medical services), you cannot use both these codes interchangeably. You will have to base your reporting on the work involved and the services that went into the encounter. 

According to CPT®, “Psychiatric diagnostic evaluation with medical services is an integrated biopsychosocial and medical assessment, including history, mental status, other physical examination elements as indicated, and recommendations. The evaluation may include communication with family or other sources, prescription of medications, and review and ordering of laboratory or other diagnostic studies.”

So, when reporting an assessment of a patient, you will have to look at what services your clinician performed in order to check whether you need to report 90792 or an E/M service. If your psychiatrist's orientation of the patient's evaluation was more towards "an integrated biopsychosocial and medical assessment," you will have to report 90792 and not an E/M code for the visit. 

If your clinician's evaluation of the patient was more medically or physically oriented, you will have to claim an appropriate E/M service code for the visit. You will still use these codes even if your clinician touches on some psychosocial issues.

Coding Tip: According to the CPT book, neither psychotherapy services nor psychotherapy for crisis may be reported on the same day as the psychiatric diagnostic evaluation. Time constraints usually mean that psychotherapy couldn’t be provided on the day of the diagnostic evaluation. An E/M service may not be billed on the day of the service, either. If psychotherapy is performed on the day of an evaluation, use an E/M service based on the medical-decision-making for codes 99202-99215 and add the psychotherapy add-on code.

CPT does not allow reporting of psychotherapy codes or psychotherapy for crisis code with 90791 or 90792.

Payer-Specific Guidelines

Although CPT allows for flexibility in use, some payers limit the number or frequency of these evaluations. Practices should confirm whether prior authorization is required and verify if the provider is credentialed to perform and bill for the service. Where relevant, telehealth-specific rules and modifiers (such as 95 or GT) must also be applied.

Individual Psychotherapy (CPT 90832, +90833, 90834, +90836, 90837, +90838)

There are two set of psychotherapy codes, one set is the set is for psychotherapy only, most frequently used by psychologists, social workers and other licensed mental health professionals. The second set of individual psychotherapy code sets are add-on codes.  CPT distinguishes between standalone psychotherapy codes and psychotherapy add-on codes, depending on whether the session includes medical management.

CPT defines psychotherapy as a structured therapeutic intervention that aims to treat emotional disturbances and maladaptive behaviors through therapeutic communication. The objective is to support behavioral change, improve functioning, and encourage emotional and personality development.

Standalone Psychotherapy Codes

The primary psychotherapy codes—90832, 90834, and 90837—are used when psychotherapy is provided without any medical evaluation or management. Non-prescribing behavioral health professionals typically bill these codes. Each code corresponds to the duration of the psychotherapy session:

• 90832: 30 minutes
• 90834: 45 minutes
• 90837: 60 minutes

These are time-based codes and follow the CPT midpoint rule, meaning the provider must perform more than half of the time stated to report the code. For example, 90832 (30 minutes) requires at least 16 minutes of service.

Notably, these codes do not differentiate based on the therapy modality (e.g., CBT, psychodynamic) or the care delivery setting. They are strictly tied to time and the delivery of therapeutic interaction with the individual patient.

Psychotherapy Add-On Codes

The second set of codes—+90833, +90836, and +90838—are add-on codes used when psychotherapy is delivered with an E/M service (i.e., when medication management and psychotherapy occur during the same visit). Psychiatrists, psychiatric NPs, and PAs typically use these. They are not reported independently but must be billed in conjunction with an E/M code.

• +90833: Add-on for psychotherapy (30 minutes)
• +90836: Add-on for psychotherapy (45 minutes)
• +90838: Add-on for psychotherapy (60 minutes)

 

The E/M service and the psychotherapy must be documented and delineated in the clinical note, including time spent on each.

Individual vs. Family Therapy

Since 2017, the CPT description for individual psychotherapy has been updated to specify that it is “with the patient” only. This clarified how to code sessions that involve other participants.

• Use individual psychotherapy codes when the focus of treatment is the individual patient, even if a spouse, caregiver, or family member is present during some or all of the session.
• Use family therapy codes when the focus of the intervention is the relationship or the family system as a whole rather than one individual’s mental health symptoms.

Psychotherapy for Patients in Crisis (CPT 90839, +90840)

Psychotherapy for crisis is used when patients present with urgent, life-threatening, or complex behavioral health concerns that demand immediate attention. These sessions involve intensive intervention aimed at stabilizing the patient and preventing psychological or physical harm.

According to CPT, crisis psychotherapy includes:

“An urgent assessment and history of a crisis state, a mental status exam, and a disposition. The treatment includes psychotherapy, mobilization of resources to defuse the crisis and restore safety, and implementation of psychotherapeutic interventions to minimize the potential for psychological trauma.”

The presenting concern must be significant, often involving high emotional distress or suicidal ideation, and require immediate, focused clinical intervention.

Code Description and Usage

• CPT 90839 is used for the first 60 minutes of crisis psychotherapy.
• +90840 is an add-on code used for each additional 30 minutes of service beyond the initial hour.

These codes are not restricted by place of service and can be billed in various settings, including outpatient offices, emergency departments, or other clinical environments. They are intended to reflect face-to-face time with the patient and/or a family member during a behavioral health crisis.

Key points for reporting psychotherapy for crises. 

• These codes are used by psychiatrists, NPs, PAs, social workers, psychologists and other licensed mental health providers. 
• These are time based codes. Document time in the medical record, including only face-to-face time with the patient and/or family member
• If the patient calls for an urgent appointment but is not in the crisis, use a psychotherapy code. 

Medication Management In Mental Health Billing

Medication management performed by psychiatric, psychiatric nurse practitioners and physician assistants is billed by Evaluation and Management (E/M) codes. This could be any type of E/M service, nursing facility service, or home visit but it is typicall billed as an office/outpatient visit for an established patient using codes 99212, 99213, 99214, 92215. 

Providing only medical management at the visit:

• May use time or MDM to select the level of service
• If based on time, use total time of visit on that date of service. 

Medication management and psychotherapy on the same calendar day

Select the level of service of office visit codes 99202 - 99215 (or other E/M service) based on MDM, not time. The time used in medication management service may not be included in the time of the psychotherapy.

In a visit, there is no sharp line between the medication management and the psychotherapy, they’re integrated into the service. This is how we must document and report the services. Start and stop times are not required by CPT, but check your payer policies. 

Coding Tip: 

If providing both medication management and psychotherapy, the practitioner must use MDM to select an office visit code and then select a psychotherapy code based on the time of the psychotherapy alone. Document a separate and distinct description of the psychotherapy with patient-specific details. Psychotherapy documentation must stand alone.  

Documentation Requirements

The clinical note must support the chosen code level. At a minimum, documentation should include:

• The diagnosis or symptoms being treated.
• A summary of the medication assessment and decision
• Any changes made to the regimen
• Time spent (if time-based coding is used)
• Relevant patient education or coordination of care activities

Interactive Complexity (CPT +90785)

Interactive complexity refers to specific communication challenges or external factors that complicate the delivery of behavioral health services. Code +90785 is used as an add-on code, meaning it must be reported in conjunction with another qualifying primary service.

When to Use Code +90785

This code may be added to the following procedures:

• Psychiatric diagnostic evaluations: 90791 or 90792
• Individual psychotherapy with or without E/M: 90833–90838
• Group psychotherapy: 90853

It may not be reported with:

• E/M services without psychotherapy
• Psychotherapy for crisis (90839, 90840)

According to CPT, typical scenarios involve:

• Patients with another individual legally responsible for their care, such as minors or adults with a legal guardian
• Involvement of interpreters or language translators
• Requests by the patient for others (e.g., family members) to be involved in the session
• Mandatory third-party participation, such as through child welfare agencies, probation officers, or school personnel

These factors require the provider to navigate more complex interpersonal dynamics and often necessitate additional documentation, coordination, or modifications in communication strategy.

Documentation Guidelines

When billing +90785, documentation should identify the specific complicating factor that necessitated the add-on. While only one of the listed factors is required, the rationale must be well-supported in the patient record.

Note: Interactive complexity does not represent routine family involvement or translation services; its use should reflect a notable departure from typical clinical interactions due to the complexity of the situation.

Group Therapy (CPT 90853)

Group psychotherapy is billed under CPT code 90853, which covers therapeutic sessions involving multiple patients participating in a shared intervention. Unlike individual psychotherapy codes, 90853 is not time-based. According to CPT, one unit of service is billed per participant, regardless of the exact session duration.

Session Structure and Payer Guidelines

Group sessions typically last 45 to 50 minutes, although session length may vary. Some payers impose a maximum group size, commonly limiting sessions to 12 participants. Many insurers also require the number of participants to be documented in each patient's chart.

Documentation Requirements

Group therapy documentation should contain:

• A shared summary of the group's therapeutic goals, topic focus, and techniques used (same for all participants)
• The number of attendees present
• Clinician interventions and how the session was guided
• A distinct note for each participant, describing their participation, responses, and progress toward treatment goals

Properly separating general group content from individualized clinical observations ensures both compliance and accurate clinical tracking.

Family Psychotherapy (CPT 90846, 90847)

Family therapy addresses the relational or family dynamics that contribute to a patient's behavioral health condition. CPT® includes two codes:

• 90846: Family psychotherapy without the patient present (50 minutes)
• 90847: Family psychotherapy, with the patient present (50 minutes)

Medicare Status and Payer Recognition

While 90847 is recognized under the Medicare fee schedule, 90846 carries a Medicare status indicator of "restricted," meaning each payer determines coverage and payment. It is essential to verify payer-specific policies before billing 90846.

Documentation Guidelines

Each session note should clearly state the following:

• Who was present during the session
• The family dynamics or interactions discussed
• The psychotherapeutic focus and techniques used
• A description of progress made toward family or relational goals

Even though the therapy may not be focused on one individual, providers must document how the session supports the mental or behavioral health treatment plan of the identified patient.

Payer Policies for Behavioral Health Services

Understanding how payer policies affect billing for behavioral health services is essential for accurate claim submission and reimbursement. Coverage and billing privileges depend on the provider’s scope of practice and licensure status, which may vary significantly across payers and state jurisdictions.

Scope of Practice and Reimbursement Eligibility

Each payer—including commercial insurers and government programs such as Medicare and Medicaid—defines which provider types it will reimburse for behavioral health services. This typically depends on the services rendered (e.g., psychotherapy vs. medical management) and whether the provider operates within their legal scope of practice.

Variability by State and Payer

Licensure requirements and billing privileges vary across all states. Some states permit independently licensed counselors to practice and bill independently, while others may require collaborative agreements or limit reimbursement to specific credentials. Commercial payers may also have enrollment processes and credentialing rules that define which provider types can bill to particular codes.

Important: Always verify state licensure rules and payer-specific policies before billing behavioral health services to ensure that the provider is eligible and properly credentialed.

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