90838 CPT Code: How to Use, Modifier and Everything else
Guide
As a mental health professional, mastering CPT codes is crucial for accurate billing and optimal reimbursement. This comprehensive guide focuses on CPT code 90838, which is essential for billing 60-minute individual psychotherapy sessions. For a comprehensive guide to all CPT codes with cheat sheet and examples, refer here.
What is CPT Code 90838?
CPT code 90838 is a service code defined as:
"Psychotherapy, 60 minutes with patient and/or family member"
This CPT code is used for individual psychotherapy sessions that last 60 minutes, with the patient physically present for the session. It's a crucial billing code for mental health professionals providing standard one-hour therapy sessions. Unlike some other psychotherapy codes, 90838 is specifically designed to be used in conjunction with (E/M) Evaluation and Management services, making it an essential tool in the arsenal of psychiatrists and other medical professionals who provide both medication management and psychotherapy services.
Historical Context and Development
Historically, psychotherapy services were billed using a more limited set of codes, which didn't always accurately reflect the time and complexity involved in different types of sessions.
The development of 90838 and related codes (such as 90833 for 30-minute sessions and 90836 for 45-minute sessions) allowed for more precise billing, particularly for psychiatrists and other medical professionals who combine psychotherapy with E/M services. This evolution in coding practices has helped to better align reimbursement with the actual services provided, supporting the financial viability of comprehensive mental health care.
Who Can Use CPT Code 90838?
CPT code 90838 can be used by a wide range of mental health professionals, including:
Psychiatrists
Psychologists
Clinical Social Workers
Licensed Professional Counselors
Marriage and Family Therapists
Psychiatric Nurse Practitioners
Any qualified health care professional providing and billing for therapeutic services can use this code, provided they meet the necessary licensing and credentialing requirements. However, it's particularly relevant for providers who combine psychotherapy with E/M services, such as psychiatrists managing both medication and providing therapy.
Session Length and Time Requirements
The time requirement for CPT code 90838 is specific:
Standard duration: 60 minutes
Minimum time: 53 minutes
Maximum time: 67 minutes
It's crucial to document the exact start and end times of your sessions in the medical record to support the use of this code. Sessions that fall outside this range may require the use of different CPT codes. For example, shorter sessions might use 90833 (30 minutes) or 90836 (45 minutes), while longer sessions might require the use of add-on codes.
Documentation Requirements
Proper documentation is essential when billing CPT code 90838. Your clinical notes should include:
Session date
Start and end times of the session
Patient's diagnosis (e.g., major depressive disorder, anxiety disorder, mood disorder)
Therapeutic interventions used
Topics covered during the session
Patient's response to treatment
Any updates or changes to the patient's psychiatric diagnostic profile based on the session's content
Progress towards treatment plan goals
Any adjustments to the treatment plan
Plan for future sessions
Any coordination with family members or other healthcare providers
If applicable, any medication management discussions or decisions
Example documentation snippet:
"60-minute individual psychotherapy session (3:00 PM - 4:00 PM) with Jane Doe, diagnosed with bipolar II disorder, a type of mood disorder (F31.81). Used cognitive-behavioral techniques to address ongoing symptoms of hypomania and depressive episodes. Patient reported improved mood stability and sleep patterns this week. Discussed and practiced mood tracking and regulation techniques. Reviewed current mood stabilizer medication regimen; no changes needed at this time. Plan to continue weekly sessions focusing on relapse prevention strategies."
Remember, your documentation should clearly demonstrate the medical necessity of the 60-minute session and justify the use of CPT code 90838. This is particularly important when dealing with insurance companies, who may require detailed justification for extended sessions.
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Modifiers and Their Use
Modifiers may be required or recommended when using CPT code 90838, depending on the specific situation and payer policies. Common modifiers include:
-25: Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service
-52: Reduced Services
-59: Distinct Procedural Service
-95: Synchronous Telemedicine Service Rendered Via Real-Time Interactive Audio and Video Telecommunications System
The use of modifiers can help clarify the nature of the service provided, particularly when 90838 is used in conjunction with other services. For example, the -25 modifier is often used when billing 90838 alongside an E/M service to indicate that the psychotherapy was a significant, separately identifiable service.
Always check with the specific payer for their requirements regarding modifier use with 90838.
Frequency of Use
The frequency of using CPT code 90838 should be based on the individual patient's needs and treatment plan. There are no universal limits on how often this code can be used, but consider the following:
The frequency should align with the patient's treatment plan and progress
Some insurance plans may have limits on the number of 60-minute sessions covered per year
Always document the medical necessity for the frequency of extended sessions
It's important to regularly review and adjust the treatment plan as needed, ensuring that the frequency of 60-minute sessions remains appropriate for the patient's care. For some patients with complex mental health conditions, such as severe major depressive disorder or treatment-resistant anxiety disorders, more frequent use of 90838 may be justified.
Use of 90838 with Evaluation and Management (E/M) Services
CPT code 90838 is unique among psychotherapy codes in that it's designed to be used in conjunction with Evaluation/Management servics. This makes it particularly useful for psychiatrists and other medical professionals who provide both medication management and psychotherapy in the same session.
When using 90838 with an E/M service:
Bill the appropriate E/M code (e.g., 99213 for an established patient office visit)
Add 90838 to indicate that 60 minutes of psychotherapy was provided in addition to the Evaluation/Management service
Use modifier -25 with the E/M code to indicate that it was a significant, separately identifiable service
Example: 99213-25 (Office visit for established patient) 90838 (60-minute psychotherapy add-on)
This combination allows for appropriate reimbursement for both the medical management and the extended psychotherapy provided in a single session.
90838 vs. Other Psychotherapy Codes
Understanding how 90838 relates to other psychotherapy codes is crucial for accurate billing:
90832: Used for 30-minute psychotherapy sessions (16-37 minutes)
90834: Used for 45-minute psychotherapy sessions (38-52 minutes)
90837: Used for 60-minute psychotherapy sessions (53 minutes or more)
Difference between 90838 and 90837
The main difference between 90837 and 90838 is that 90838 is an add-on code used in conjunction with an Evaluation and Management (E/M) service, while 90837 is a standalone code for psychotherapy.
Other related codes include:
90839: Used for psychotherapy for crisis (first 60 minutes)
90840: Add-on code for each additional 30 minutes of crisis therapy
90853: Used for group psychotherapy
When deciding between these psychotherapy codes, consider the nature of the service provided, the time spent, and whether the session included E/M components.
90838 in the Context of Various Mental Health Conditions
CPT code 90838 can be used for a wide range of mental health conditions, including but not limited to:
Major Depressive Disorder
Anxiety Disorders
Bipolar Disorder and any other mood disorder
Post-Traumatic Stress Disorder (PTSD)
Obsessive-Compulsive Disorder (OCD)
Personality Disorders
Psychiatric diagnostic
The use of 60-minute sessions may be particularly beneficial for complex cases or when addressing multiple issues in a single session. For example, a patient with comorbid major depressive disorder and anxiety disorder might benefit from extended sessions to address both conditions comprehensively.
When using 90838 for specific conditions, ensure that your documentation clearly outlines how the extended session time was necessary for addressing the patient's particular mental health needs.
Telehealth Considerations
With the increasing prevalence of telehealth in mental health care, it's important to understand how CPT code 90838 can be used in virtual settings:
90838 can be billed for telehealth sessions, provided they meet the time requirements
Use the appropriate telehealth modifier (usually -95) when billing
Ensure you're using a HIPAA-compliant platform for telehealth sessions
Document that the session was conducted via telehealth in your notes
Be aware of any state-specific regulations regarding telehealth services
The ability to bill 90838 for telehealth sessions has been crucial in maintaining access to extended psychotherapy services during times when in-person visits may be limited or impossible.
Best Practices and Common Pitfalls
To ensure proper use of CPT code 90838 here are some best practices:
Always document session start and end times accurately
Ensure your documentation supports the medical necessity of a 60-minute session
Be aware of any payer-specific guidelines or limitations
Regularly audit your billing practices to ensure compliance
Stay updated on any changes to CPT codes or billing requirements
Use appropriate modifiers when necessary
Clearly differentiate between the E/M portion and the psychotherapy portion of the session in your documentation
Common pitfalls to avoid:
Using 90838 for sessions shorter than 53 minutes
Failing to document the medical necessity for a 60-minute session
Not using required modifiers
Overusing 90838 without proper justification
Neglecting to bill the associated E/M code when appropriate
Inconsistent documentation between the Evaluation/Management service and the psychotherapy service
Reimbursement Considerations
Reimbursement rates for CPT code 90838 can vary significantly based on several factors:
Insurance provider policies
Geographic location
Provider credentials
Complexity of the case
It's important to note that reimbursement rates are not uniform across all insurance companies or regions. To navigate these variations:
Consult directly with insurance companies to obtain current reimbursement rates
Be aware of geographic influences on reimbursement
Stay informed about potential rate changes
Align your billing practices with specific insurance provider requirements
Remember, understanding the nuances of insurance policies and staying informed about reimbursement rates is crucial for maintaining the financial health of your practice. Some insurance companies may have specific policies regarding the frequency of 60-minute sessions or may require additional justification for their use over shorter session codes.
The Future of Psychotherapy Coding
As mental health care continues to evolve, it's likely that we'll see further refinements in psychotherapy coding. Some potential future developments might include:
More nuanced codes for specific types of psychotherapy (e.g., trauma-focused CBT, DBT)
Codes that better account for the intensity of services provided
Enhanced integration of physical and mental health codes
Codes specifically designed for emerging treatment modalities or technologies
Staying informed about these potential changes will be crucial for mental health professionals to ensure they're using the most appropriate and up-to-date codes for their mental health services.
Frequently Asked Questions
Can I use 90838 for telehealth sessions?
Yes, 90838 can be used for telehealth sessions. Be sure to use the appropriate telehealth modifier (usually -95) and check with the payer for any specific telehealth billing requirements.
How does 90838 differ from 90837?
While both codes are for 60-minute sessions, 90838 is an add-on code used with E/M services, while 90837 is a standalone psychotherapy code.
Can I bill 90838 multiple times in one day for the same patient?
Generally, 90838 should only be billed once per day per patient. If you have multiple distinct sessions with the same patient in one day, consult with the payer for their specific policies.
Do I need to use a modifier with 90838?
It depends on the specific circumstances and payer requirements. Always check with the individual payer for their modifier policies. When used with an E/M service, the E/M code typically requires the -25 modifier.
How do I justify the use of 90838 instead of a shorter session code?
Your documentation should clearly indicate why a 60-minute session was necessary for the patient's care. This could include the complexity of the case, the need for more intensive interventions, or other clinical factors that require extended time.
Can 90838 be used for group psychotherapy?
No, 90838 is specifically for individual psychotherapy. For group psychotherapy, you would use a different code, such as 90853.
How does interactive complexity affect the use of 90838?
If the session involves interactive complexity, you can add the interactive complexity add-on code (90785) in addition to 90838.
Can I use 90838 for a new patient office visit?
Yes, you can use 90838 for a new patient, but remember it's an add-on code. You would bill the appropriate E/M code for a new patient visit (e.g., 99205) along with 90838.
Remember, while this guide provides general information, always consult with individual payers and stay updated on the latest billing guidelines to ensure compliance and optimal reimbursement. Mental health billing can be complex, but understanding codes like 90838 is crucial for providing comprehensive mental health care while maintaining a financially viable practice.