CPT code 90838 is the add-on code for extended psychotherapy (53+ minutes) when performed in conjunction with an Evaluation and Management (E/M) service. For psychiatrists and other prescribers who combine medication management with intensive psychotherapy, mastering 90838 billing is essential to capturing the full value of your clinical work.
This code represents the highest-tier psychotherapy add-on, designed for complex patient encounters where both medical evaluation and extended therapeutic intervention occur in the same visit. Understanding when and how to bill 90838 correctly can significantly impact your practice revenue while ensuring compliance with payer requirements.
What Is CPT Code 90838?
CPT 90838 is an add-on code for psychotherapy services lasting 53 minutes or more when performed with an Evaluation and Management (E/M) service on the same day. Unlike standalone psychotherapy codes (90832, 90834, 90837), the 9083X series (90833, 90836, 90838) can only be billed in conjunction with a primary E/M code.
The American Medical Association (AMA) defines 90838 as: "Psychotherapy, 53 minutes or more of psychotherapy with patient when performed with an evaluation and management service (List separately in addition to the code for primary procedure)."
This code is primarily used by psychiatrists and other medical professionals who provide both medication management and psychotherapy during the same encounter. The combination captures the full scope of services rendered during complex psychiatric visits.
Key Characteristics of 90838
- Add-on code status: Cannot be billed alone; requires a base E/M code
- Time requirement: 53 or more minutes of psychotherapy
- Provider types: Primarily psychiatrists, psychiatric nurse practitioners, and other prescribing mental health providers
- Service combination: E/M component plus extended psychotherapy in same encounter
- Setting: Outpatient, inpatient, partial hospitalization, or telehealth
- Time tracking: Only psychotherapy time counts toward 90838; E/M time is separate
Critical Distinction: Add-On vs. Standalone Codes
Do not confuse 90838 with 90837. While both require 53+ minutes of psychotherapy, 90837 is a standalone code billed without an E/M service, and 90838 is an add-on that must accompany an E/M code. Billing 90838 without an E/M code will result in automatic claim denial. Similarly, billing 90837 when you also perform and bill an E/M service is incorrect.
Time Requirements and Calculation
Understanding how to calculate and document time for 90838 is essential for accurate billing. The 53-minute threshold applies specifically to face-to-face psychotherapy time, separate from the E/M component of the visit.
Psychotherapy Add-On Code Time Ranges
| CPT Code | Psychotherapy Time | Requires E/M | 2024 Medicare Rate |
|---|---|---|---|
| 90833 | 16-37 minutes | Yes | $50.23 |
| 90836 | 38-52 minutes | Yes | $74.38 |
| 90838 | 53+ minutes | Yes | $94.71 |
Separating E/M Time from Psychotherapy Time
When billing 90838 with an E/M code, you must track two distinct time components. These times should not overlap, and your documentation must clearly distinguish between the two services.
E/M Service Time Includes
- • History taking for medical evaluation
- • Physical or mental status examination
- • Medical decision making
- • Medication review and prescribing
- • Lab result discussion
- • Side effect assessment
- • Treatment planning for medical component
Psychotherapy Time (90838) Includes
- • Therapeutic interventions (CBT, DBT, etc.)
- • Insight-oriented therapy
- • Supportive psychotherapy
- • Trauma processing
- • Behavior modification
- • Crisis intervention
- • Cognitive restructuring
Time Documentation Best Practice
Document time explicitly for each component. Example: "Total encounter time: 75 minutes. E/M component: 20 minutes (medication review, side effect assessment, prescribing). Psychotherapy component: 55 minutes (CBT interventions for anxiety, cognitive restructuring, exposure planning)." This clear separation supports both codes and protects against audits.
Required Base E/M Codes
CPT 90838 must be paired with an appropriate Evaluation and Management code. The E/M code you select depends on the setting, complexity of medical decision making, and total E/M time spent.
Common E/M Codes Used with 90838
| E/M Code | Description | Typical Use | 2024 Medicare |
|---|---|---|---|
| 99213 | Office visit, established patient, low complexity | Stable patient, routine med check | $77.32 |
| 99214 | Office visit, established patient, moderate complexity | Med adjustment, new symptoms | $113.52 |
| 99215 | Office visit, established patient, high complexity | Complex medication regimen | $152.89 |
| 99204 | Office visit, new patient, moderate complexity | Initial psych evaluation with meds | $166.87 |
| 99205 | Office visit, new patient, high complexity | Complex new patient, multiple diagnoses | $211.46 |
Selecting the Right E/M Level
E/M code selection is based on either total time or medical decision making (MDM) complexity. For psychiatric visits, MDM often drives the selection:
- Low complexity (99213): Stable patient on current medications, no significant changes, straightforward management
- Moderate complexity (99214): Medication adjustment needed, new or worsening symptoms, managing prescription drug with monitoring requirements
- High complexity (99215): Multiple psychotropic medications, significant drug interactions, severe or treatment-resistant illness, suicide risk management
Audit Alert: E/M Level Selection
Payers closely scrutinize E/M levels billed with psychotherapy add-ons. Consistently billing 99215 with 90838 will trigger audits. Most established patient psychiatric visits with medication management appropriately fall in the 99213 or 99214 range. Reserve 99215 for genuinely complex cases and document the medical decision making thoroughly.
90838 vs 90836 vs 90833: Choosing the Right Add-On
The psychotherapy add-on code family (90833, 90836, 90838) follows the same time-based structure as standalone codes. Selection depends entirely on the psychotherapy time provided during the encounter.
Best For:
- Brief supportive therapy with med check
- Medication-focused visits with some counseling
- Stable patients needing check-in
- Follow-up visits with limited therapy needs
Combined reimbursement (with 99214):
$163.75
Best For:
- Standard combined visits
- Ongoing psychotherapy with meds
- Moderate complexity therapy needs
- Most medication management + therapy visits
Combined reimbursement (with 99214):
$187.90
Best For:
- Complex trauma with medication
- Crisis intervention + med adjustment
- Intensive treatment phases
- Treatment-resistant cases needing dual approach
Combined reimbursement (with 99214):
$208.23
Medicare vs Commercial Reimbursement Rates
Reimbursement for 90838 varies based on payer, geographic location, and the E/M code paired with it. Since 90838 is an add-on code, your total reimbursement combines both the E/M and psychotherapy add-on amounts.
2024 Medicare Rates for 90838
| Location | 90838 Rate | With 99214 | With 99215 |
|---|---|---|---|
| National Average | $94.71 | $208.23 | $247.60 |
| New York City Metro | $104.62 | $229.89 | $273.46 |
| San Francisco Bay Area | $108.78 | $239.03 | $284.34 |
| Los Angeles Metro | $102.09 | $224.32 | $266.83 |
| Rural Areas | $86.25 | $189.65 | $225.63 |
Commercial Payer Rates
Commercial insurance typically reimburses higher than Medicare, though rates vary significantly by payer and contract. Here are typical ranges for 90838 combined with 99214:
Blue Cross Blue Shield
$235-290
Combined E/M + 90838
UnitedHealthcare
$225-275
Combined E/M + 90838
Aetna
$220-270
Combined E/M + 90838
Cigna
$230-285
Combined E/M + 90838
Documentation Requirements
Documentation for 90838 claims must support both the E/M service and the extended psychotherapy component. Each element must be clearly documented to withstand payer review and potential audits.
Essential Documentation Checklist for 90838
Sample Documentation Structure
A well-structured note for 90838 + E/M billing might follow this format:
DATE: [Date of service]
TOTAL ENCOUNTER TIME: 78 minutes
E/M COMPONENT (22 minutes):
- Reviewed current medications: sertraline 100mg, trazodone 50mg PRN
- Discussed side effects: reports improved sleep, mild nausea resolved
- Lab review: CBC and metabolic panel within normal limits
- Medical decision making: Moderate complexity; continuing current regimen with addition of buspirone 5mg BID for breakthrough anxiety
PSYCHOTHERAPY COMPONENT (56 minutes):
- Individual psychotherapy using CBT framework
- Addressed cognitive distortions related to work performance anxiety
- Practiced cognitive restructuring techniques
- Introduced behavioral activation scheduling
- Patient demonstrated understanding and engagement with interventions
ASSESSMENT: Generalized anxiety disorder, improving with combined treatment approach
PLAN: Continue sertraline 100mg, add buspirone 5mg BID, continue weekly psychotherapy focusing on CBT interventions
Payer-Specific Billing Rules
Each major payer has unique requirements for 90838 billing. Knowing these rules prevents denials and accelerates reimbursement.
Medicare
- Accepts 90838 when billed with appropriate E/M codes by qualified providers
- Requires clear documentation separating E/M and psychotherapy components
- Modifier GT required for telehealth claims
- Time-based E/M coding applies; document total E/M time if using time instead of MDM
- Cannot bill 90838 with psychiatric diagnostic evaluation codes (90791, 90792) on same date
Blue Cross Blue Shield
- Rules vary by state BCBS entity; verify local requirements
- Some plans require prior authorization for extended psychotherapy
- May request treatment reports for high-frequency 90838 billing
- Modifier 95 typically required for telehealth
UnitedHealthcare / Optum
- Optum manages behavioral health benefits for many UHC plans
- May require concurrent review for ongoing intensive services
- Documentation requests common for combined E/M + psychotherapy claims
- Verify credentialing covers both E/M and psychotherapy billing
Aetna
- Generally accepts 90838 from credentialed prescribers
- Pre-certification may be required after initial evaluation period
- Strong documentation of medical necessity expected
- Appeals process available for denied claims
Cigna
- Evernorth behavioral health division handles claims
- Treatment plans required and must show progress
- May audit high-volume 90838 billers
- Consistent telehealth coverage maintained
Common Denial Reasons and Prevention
Understanding why 90838 claims get denied helps you prevent issues proactively. Here are the most frequent denial reasons and strategies to address them.
Missing or Incorrect Base E/M Code
Denial reason: 90838 billed without accompanying E/M code or with incompatible code.
Prevention: Always pair 90838 with an appropriate E/M code (99213-99215, 99203-99205). Never bill 90838 as a standalone code. Verify codes are compatible before submission.
Insufficient Time Documentation
Denial reason: Notes do not clearly support 53+ minutes of psychotherapy separate from E/M time.
Prevention: Document psychotherapy time explicitly: "56 minutes of individual psychotherapy provided." Keep E/M time and psychotherapy time clearly separated in documentation.
Provider Credentialing Issues
Denial reason: Provider not credentialed to bill E/M codes with this payer.
Prevention: Verify your credentialing explicitly covers E/M billing. Some payers credential providers separately for medical services versus mental health services. Confirm both are active.
Medical Necessity Not Established
Denial reason: Payer questions need for extended psychotherapy with medical visit.
Prevention: Document why the patient requires both medication management AND extended psychotherapy in the same visit. Reference treatment complexity, symptom severity, or integrated treatment approach needs.
Incorrect Modifier Usage
Denial reason: Telehealth claims missing required modifiers or wrong modifier applied.
Prevention: Apply appropriate telehealth modifiers (95 for commercial, GT for Medicare) to both the E/M code and 90838. Ensure Place of Service code matches service delivery method.
Real-World Billing Scenarios
Let's examine common clinical situations to determine the correct billing approach for 90838.
Scenario 1: Standard Psychiatric Follow-Up with Extended Therapy
Situation: Psychiatrist sees established patient for medication management (20 minutes reviewing meds, assessing side effects, adjusting dosage) followed by 58 minutes of CBT-focused psychotherapy for anxiety.
Correct billing: 99214 + 90838. The E/M component involves moderate complexity decision making (medication adjustment), and psychotherapy exceeds 53 minutes.
Scenario 2: New Patient with Complex Presentation
Situation: First visit with new patient. Spend 35 minutes on comprehensive psychiatric evaluation, medication history, and prescribing initial medications. Then provide 55 minutes of crisis-focused psychotherapy for acute depression.
Correct billing: 99205 + 90838. New patient with high complexity medical decision making (new psychiatric diagnosis, initiating multiple medications) plus extended psychotherapy. Document both components clearly.
Scenario 3: Telehealth Combined Visit
Situation: Video visit with established patient at their home. Medication review takes 18 minutes, followed by 54 minutes of trauma-focused psychotherapy.
Correct billing: 99214-95 + 90838-95, POS 10. Apply modifier 95 to both codes for commercial payers. Use modifier GT for Medicare. Document telehealth platform used and that patient was visible throughout.
Scenario 4: Psychotherapy Falls Short of 53 Minutes
Situation: 85-minute appointment total. E/M component takes 25 minutes, psychotherapy component is 48 minutes (patient needed to leave early for another appointment).
Correct billing: 99214 + 90836 (not 90838). The 48 minutes of psychotherapy falls in the 38-52 minute range for 90836. Do not upcode to 90838 based on scheduled time; bill based on actual service delivered.
Scenario 5: No Significant E/M Component
Situation: Patient is stable on medications. You briefly confirm medications are working (3 minutes) then provide 57 minutes of psychotherapy.
Correct billing: 90837 (standalone psychotherapy code). If the E/M component is not separately identifiable and involves minimal medical decision making, do not bill both E/M and add-on codes. Bill the standalone psychotherapy code that matches your time.
When to Use 90837 vs 90838
Use 90838 when you provide a separately identifiable E/M service (meaningful medication management, medical evaluation, or significant decision making) along with extended psychotherapy. Use 90837 when psychotherapy is the primary service and any medication discussion is incidental or minimal. The key question: "Would the E/M component stand on its own as a billable service?"
Frequently Asked Questions
Can non-prescribing therapists bill 90838?
Generally, no. CPT 90838 is designed for providers who perform both E/M services (medical evaluation and management) and psychotherapy. Non-prescribing therapists (LCSWs, LPCs, LMFTs, psychologists without prescriptive authority) should use the standalone psychotherapy codes (90832, 90834, 90837) instead. If you only provide psychotherapy without a separately identifiable medical component, the standalone codes are appropriate regardless of your credentials.
What if my psychotherapy time is exactly 53 minutes?
Yes, 53 minutes meets the threshold for 90838. The code covers "53 minutes or more" of psychotherapy, so 53 minutes exactly qualifies. Document the precise time clearly in your notes to support the billing. If you only have 52 minutes of psychotherapy time, you should use 90836 instead.
Can I bill 90838 with 99211?
This would be unusual and likely scrutinized. CPT 99211 is for minimal E/M services often performed without a physician present. If you are providing 53+ minutes of psychotherapy, you are almost certainly also providing a more substantial E/M service than 99211 represents. Most psychiatric visits with extended psychotherapy pair 90838 with 99213, 99214, or 99215 depending on the complexity of medical decision making.
Is there a maximum time limit for 90838?
There is no defined maximum, but unusually long sessions (90+ minutes of psychotherapy) may trigger payer scrutiny. If you regularly conduct very extended sessions, ensure documentation thoroughly supports medical necessity for the extended time. Consider whether crisis codes or multiple service dates might be more appropriate for very long encounters.
Can I bill 90838 with psychiatric diagnostic evaluation codes?
No. CPT 90791 (diagnostic evaluation without medical services) and 90792 (diagnostic evaluation with medical services) cannot be billed on the same date as 90838. These diagnostic codes are comprehensive and already account for the evaluation component. If you conduct a diagnostic evaluation and provide extended psychotherapy on the same day, bill only the appropriate diagnostic code.
How do I handle split billing for 90838 telehealth?
For telehealth visits, apply the appropriate telehealth modifier to both the E/M code and 90838. For commercial payers, typically use modifier 95 on both codes. For Medicare, use modifier GT. The Place of Service should be 02 (telehealth not at patient home) or 10 (telehealth at patient home). Ensure both modifiers and POS codes are consistent across all codes billed for the encounter.
What documentation supports the E/M level selection?
For most psychiatric E/M encounters, medical decision making (MDM) drives code selection. Document: (1) the number and complexity of problems addressed, (2) data reviewed or ordered (labs, records, consultations), and (3) risk of complications or morbidity from treatment. For moderate complexity (99214), you typically need moderate data review and moderate risk (e.g., prescription drug management requiring monitoring). High complexity (99215) requires high-level MDM across these categories.
Key Takeaways for CPT 90838 Billing
- CPT 90838 is an add-on code requiring a base E/M code; it cannot be billed standalone
- Requires 53+ minutes of psychotherapy time, tracked separately from E/M time
- Document E/M and psychotherapy components distinctly to support both codes
- 2024 Medicare rate for 90838 is $94.71; combined with 99214 totals approximately $208
- Use 90838 for prescribers; use standalone 90837 if no significant E/M component exists
- Apply appropriate telehealth modifiers (95 or GT) to both E/M and add-on codes
Streamline Your Combined E/M and Psychotherapy Billing
Managing the complexity of combined E/M and psychotherapy billing requires careful attention to time tracking, documentation, and payer requirements. TheraFocus practice management software simplifies this process with integrated features designed specifically for psychiatric and prescriber practices.
Our automated time tracking captures both E/M and psychotherapy components separately, ensuring accurate code selection. Smart documentation templates include all required elements for 90838 billing while maintaining clear separation between service components. Real-time eligibility verification helps you confirm patient coverage before appointments.
Ready to reduce billing complexity and focus more on patient care? Discover how TheraFocus helps psychiatric practices optimize their revenue cycle while maintaining compliance with payer requirements.
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