2025 CPT code 90838
(Active) Effective Date: N/A Psychiatry - Psychotherapy Feed
Individual psychotherapy, 60 minutes with patient, performed with an evaluation and management (E/M) service.
Modifiers may be applicable depending on the specific circumstances. Check payer guidelines.
Medical necessity for both the E/M and psychotherapy services must be documented. The documentation should show that the services were reasonable and necessary for the diagnosis and treatment of the patient's condition.
The healthcare provider conducts a 60-minute psychotherapy session using various therapeutic techniques to address the patient's mental health needs. This is done in conjunction with a separate E/M service also performed by the provider. Documentation should reflect both the psychotherapy and E/M components.
In simple words: This code covers a 60-minute psychotherapy session with your healthcare provider, along with a separate medical check-up, during the same visit. The therapy session focuses on understanding your thoughts, feelings, and behaviors to address mental health concerns.The medical check-up is billed separately.
This code represents individual psychotherapy lasting 60 minutes (time range: 53 minutes or more) with the patient present, when performed in addition to a separate and identifiable E/M service.The psychotherapy includes insight-oriented, behavior-modifying, and/or supportive techniques. It may involve family members if clinically appropriate. The E/M service is reported separately.
Example 1: A patient with depression sees a psychiatrist for medication management (E/M service) and a 60-minute psychotherapy session to discuss coping strategies., A patient with anxiety receives a medical evaluation (E/M service) for physical symptoms, followed by a 60-minute psychotherapy session to address anxiety-provoking situations., A patient with bipolar disorder has a medication check-up (E/M service) and then engages in a 60-minute psychotherapy session focused on mood stabilization techniques.
Documentation must support both the E/M service and the psychotherapy service. For psychotherapy, it should include the patient's presenting problem, the type of therapy provided, interventions used, patient response, and treatment plan. For the E/M service, documentation should follow standard E/M guidelines.
** Always verify current coding guidelines and payer policies for the most up-to-date information.As of December 1st, 2024, this information is current but may be subject to change. Consider using specialized tools like iFrameAI for comprehensive and accurate information.
- Specialties:Psychiatry, Psychology, Clinical Social Work, Licensed Professional Counseling, Marriage and Family Therapy, Psychiatric Nursing
- Place of Service:Office, Outpatient Hospital, Inpatient Hospital, Telehealth Provided in Patient’s Home, Telehealth Provided Other than in Patient’s Home