CPT 90846 is one of the most misunderstood codes in mental health billing. It covers family psychotherapy sessions where the identified patient is not present, typically involving parents, spouses, or other family members. While this code serves a critical clinical purpose, it also triggers more payer scrutiny, more denials, and more confusion than almost any other therapy code.
This guide explains exactly when to use 90846, how it differs from 90847, what documentation you need to get paid, and why some payers restrict or deny this code entirely. Whether you are consulting with parents about their child's treatment or meeting with a spouse to discuss family dynamics, understanding 90846 is essential for compliant billing.
What is CPT 90846?
CPT 90846 is defined by the American Medical Association as "Family psychotherapy (without the patient present), 50 minutes." This code is used when you provide therapeutic services to family members to address issues that directly affect the identified patient's mental health treatment, but the patient themselves is not in the room.
The key distinction here is that even though the patient is absent, the session must still be focused on the patient's treatment. You are not simply providing therapy to the family member. You are working with family members as part of the identified patient's overall treatment plan.
Common Clinical Scenarios for 90846
- Parent consultation for child therapy - Meeting with parents to discuss treatment progress, coordinate behavioral interventions at home, or address family dynamics affecting the child
- Spouse or partner sessions - Working with a partner to improve their understanding of the patient's condition and how to provide support
- Caregiver training - Teaching family members skills to support a patient with severe mental illness, dementia, or developmental disorders
- Family systems work - Addressing dysfunctional family patterns that maintain the patient's symptoms, when the patient cannot or should not be present
- Coordination of care - Therapeutic work with family to align home environment with treatment goals
What Does "Without Patient Present" Actually Mean?
The phrase "without patient present" creates significant confusion. Here is what it means in practice: the identified patient (the person whose insurance is being billed, the person with the diagnosis being treated) is not physically or virtually present during the session. However, the entire session must still focus on that patient's treatment.
Critical Distinction
CPT 90846 is NOT for providing individual therapy to a family member who happens to be related to your patient. If you are treating the family member's own depression, anxiety, or other condition, that person becomes your patient and you bill their insurance with individual therapy codes (90834, 90837, etc.). CPT 90846 is only appropriate when the session focuses on the identified patient's treatment, even though that patient is absent.
Why Would the Patient Be Absent?
There are several clinically appropriate reasons for conducting family therapy without the patient:
- Age-appropriate exclusion - Young children should not be present for adult discussions about their diagnosis, prognosis, or family conflicts
- Safety concerns - Discussions about domestic violence, abuse, or high-conflict situations may be unsafe with the patient present
- Developmental appropriateness - Some content is not appropriate for the patient's developmental level
- Treatment strategy - Parents may need coaching on behavioral interventions before implementing them with the child
- Patient refusal - The patient declines to attend but family work is still clinically necessary
- Patient incapacity - Severe mental illness, cognitive impairment, or medical condition prevents participation
When to Use 90846 vs 90847
The difference between these two codes is straightforward on paper but frequently confused in practice. The deciding factor is simple: is the identified patient in the session or not?
- •Family members only in session
- •Session still focuses on identified patient
- •Billed to patient's insurance
- •Higher payer scrutiny
- •Some payers do not cover
- •Example: Parent training for child's behavior
- •Identified patient attends session
- •Family members also present
- •Billed to patient's insurance
- •More widely accepted by payers
- •Lower denial rates
- •Example: Family session with teen and parents
Billing Tip: Partial Attendance
What if the patient is present for part of the session but not all of it? If the identified patient participates in any meaningful portion of the session, most billing experts recommend using 90847. Reserve 90846 for sessions where the patient is completely absent. Document clearly: "Patient present for first 15 minutes, then excused. Remainder of session (35 minutes) focused on parent training for behavioral interventions."
Time Requirements for CPT 90846
Unlike the individual psychotherapy codes (90832, 90834, 90837) which have specific time ranges, CPT 90846 is described as a 50-minute service. However, the time requirements are interpreted differently by different payers.
The 50-Minute Standard
The AMA descriptor states "50 minutes." Most payers interpret this as a typical session length, not a strict minimum. In practice:
- Sessions should typically be around 50 minutes
- Brief sessions (under 30 minutes) may not be appropriate for this code
- There is no separate "26-minute" family therapy code like there is for individual therapy
- Some payers apply the 50-minute standard strictly; others allow reasonable variation
No Shorter Family Therapy Code Exists
Unlike individual therapy where you can bill 90832 for 30-minute sessions, there is no corresponding shorter code for family therapy. If your family session runs only 25-30 minutes, you may face challenges billing 90846. Some practices use time-based add-on codes or simply document the shorter duration with clinical justification. Check with each payer for their specific policy on session length.
Consent and Authorization Requirements
Because you are billing the identified patient's insurance for a session they did not attend, consent and authorization requirements are particularly important for 90846.
90846 Consent Checklist
Special Considerations for Minor Patients
When the identified patient is a child or adolescent, consent dynamics change:
- Young children - Parents typically have full authority to consent to treatment and participate in family sessions
- Adolescents - State laws vary on adolescent privacy rights; some information shared in individual therapy may be confidential from parents
- Divorced/separated parents - Clarify custody arrangements and who has authority to consent to treatment and participate in sessions
- Documentation - Note in the chart who provided consent and their relationship to the patient
Medicare vs Commercial Reimbursement Rates
CPT 90846 reimbursement varies by payer and geographic location. Here are current benchmarks:
2024 Medicare Rates
| Setting | National Average | High-Cost Areas | Low-Cost Areas |
|---|---|---|---|
| Non-Facility (Office) | $121.47 | $135-150 | $105-115 |
| Facility (Hospital) | $101.22 | $112-125 | $90-100 |
Commercial Insurance Rates
Commercial payers typically reimburse 15-40% higher than Medicare for family therapy codes:
- Blue Cross Blue Shield - Typically $130-175 depending on state and plan
- Aetna - Usually $125-165 for in-network providers
- Cigna - Generally $120-160 range
- UnitedHealthcare - Approximately $125-170 depending on network tier
Rate Comparison: 90846 vs 90847
Most payers reimburse 90846 and 90847 at similar rates since both are 50-minute family therapy services. The difference in payment comes from coverage policies, not fee schedules. If a payer covers both codes, expect similar reimbursement. The challenge with 90846 is getting the claim approved in the first place.
Documentation Requirements
Documentation for 90846 requires extra care because auditors will scrutinize whether the session truly focused on the identified patient's treatment. Every note should clearly connect the family session to the patient's care.
90846 Documentation Checklist
Sample Documentation Language
Weak documentation: "Met with patient's mother. Discussed patient's behavior. Mother was receptive."
Strong documentation: "Family psychotherapy session with identified patient (J.S., 8 y/o male) absent. Mother (Mary S.) attended. Patient excluded due to age-inappropriate content regarding behavioral management strategies. Session focused on patient's treatment goal #2: Reduce oppositional behaviors at home from daily to 2x weekly. Provided psychoeducation on antecedent-behavior-consequence patterns. Trained mother in positive reinforcement techniques and planned ignoring for attention-seeking behaviors. Mother demonstrated understanding by correctly identifying reinforcement opportunities in three scenarios. Assigned behavioral tracking chart for home implementation. This session directly supports patient's treatment by equipping parent with skills to implement behavioral interventions consistently. Plan: Review behavioral data at next parent session in 2 weeks; resume individual play therapy with patient next week."
Payer-Specific Rules and Restrictions
CPT 90846 faces more coverage restrictions than almost any other therapy code. Many payers have specific policies that limit or exclude this service.
Medicare
- Generally covers 90846 when medically necessary
- Must be part of the identified patient's treatment plan
- Documentation must clearly show benefit to the patient
- Some Medicare Advantage plans may have additional restrictions
Medicaid
- Coverage varies dramatically by state
- Some states do not cover 90846 at all
- Others require specific credentials or settings
- May require prior authorization
- Often limited to certain diagnoses or age groups
Commercial Payers
Warning: Common Exclusions
Many commercial payers explicitly exclude or restrict CPT 90846. Common policies include: requiring patient presence for all family therapy (only covering 90847), limiting 90846 to specific diagnoses (autism, severe mental illness), requiring prior authorization, capping the number of sessions per year, or excluding the code entirely. Always verify coverage before providing this service.
| Payer | 90846 Coverage | Common Restrictions |
|---|---|---|
| UnitedHealthcare/Optum | Limited | Often requires medical necessity review; may prefer 90847 |
| Aetna | Plan-dependent | Some plans exclude; check member benefits |
| Cigna | Generally covered | Documentation must justify patient absence |
| BCBS (varies by state) | Varies widely | Check state-specific BCBS policies |
| Kaiser Permanente | Generally covered | For established patients in family therapy track |
Common Denial Reasons and How to Prevent Them
CPT 90846 has one of the highest denial rates among therapy codes. Understanding why claims are denied helps you prevent these issues before they occur.
1. Service Not Covered
Problem: The payer does not cover family therapy without the patient present under this plan.
Prevention: Verify benefits before the first family session. Ask specifically about 90846 coverage, not just "family therapy."
2. Medical Necessity Not Established
Problem: Documentation does not adequately explain why this service was necessary for the patient's treatment.
Prevention: Every note must explicitly connect the family session to the patient's diagnosis and treatment goals. Explain why the patient's absence was clinically appropriate.
3. Prior Authorization Required
Problem: The payer requires pre-approval for family therapy codes that was not obtained.
Prevention: Check authorization requirements when verifying benefits. Some payers require auth after a certain number of sessions.
4. Not on Treatment Plan
Problem: Family therapy is not documented as part of the patient's treatment plan.
Prevention: Update the treatment plan to include family therapy as an intervention before billing 90846.
5. Incorrect Diagnosis
Problem: The diagnosis code does not support family therapy, or the payer restricts 90846 to certain diagnoses.
Prevention: Use diagnosis codes that clearly support the need for family involvement (e.g., ADHD, conduct disorders, eating disorders, autism spectrum disorders).
6. Duplicate or Bundling Issues
Problem: Billing 90846 on the same day as individual therapy without proper modifiers, or exceeding visit limits.
Prevention: If providing both individual and family services same day, ensure they are truly separate services with separate documentation. Use modifier 59 or XE if required.
Real-World Billing Scenarios
Let us walk through common situations and how to handle billing correctly:
Scenario 1: Parent Consultation for Child Patient
Situation: You treat an 8-year-old for ADHD. You meet with both parents for 50 minutes to discuss behavioral strategies for home. The child is not present.
Answer: Bill 90846 to the child's insurance. Document that the session focused on the child's treatment (behavioral strategies for managing ADHD symptoms at home). Note why the child was excluded (age-inappropriate content, need for candid discussion between adults). Connect to treatment plan goals.
Scenario 2: Collateral Session with Spouse
Situation: Your adult patient with major depression has difficulty attending sessions during a severe depressive episode. You meet with the spouse to provide psychoeducation about depression, discuss warning signs, and coordinate support.
Answer: Bill 90846 to the patient's insurance. Document the patient's inability to attend (severity of symptoms), the focus on the patient's treatment (improving home support), and how this session supports recovery goals. Ensure you have appropriate releases on file.
Scenario 3: Family Session Where Patient Leaves Early
Situation: You conduct a family session with an adolescent and parents. After 20 minutes, the teen becomes dysregulated and leaves. You continue working with the parents for another 35 minutes.
Answer: This is a judgment call. Since the patient participated meaningfully for part of the session, many experts recommend billing 90847 (patient present). Document the full session including the patient's participation and departure. If you bill 90846, you may face more scrutiny.
Scenario 4: Training for Caregiver of Adult with Severe Mental Illness
Situation: You treat an adult with schizophrenia who lives with their elderly parents. You meet with the parents to train them on medication management, recognizing relapse warning signs, and crisis intervention.
Answer: Bill 90846. Document that the session focused on the patient's treatment (caregiver training to support medication adherence and early intervention), the clinical rationale for meeting without the patient (cognitive symptoms, caregiver-focused content), and how this supports the patient's recovery and community stability.
Scenario 5: Court-Ordered Family Therapy
Situation: A court orders family therapy for a minor in a custody dispute. The parents want to meet without the child present to discuss co-parenting.
Answer: Be careful here. If the session focuses on co-parenting and the adults' relationship rather than the child's mental health treatment, 90846 may not be appropriate. This could be considered co-parenting coordination or mediation, which is typically not covered by health insurance. Only bill 90846 if the session genuinely focuses on the child's mental health treatment needs.
Frequently Asked Questions
Can I bill 90846 for a phone call with a parent?
Generally, no. CPT 90846 is typically intended for face-to-face or video-based sessions, not telephone calls. Brief phone consultations with family members are often considered part of the patient's overall care and not separately billable. Some payers may allow telephone-based family therapy under specific circumstances, but this is not the norm. For extended phone-based family interventions, check with the specific payer about coverage policies.
My payer denied 90846 but covers 90847. What are my options?
You have several options: (1) Appeal with documentation explaining medical necessity for the patient's absence, (2) Request an exception or prior authorization for future sessions, (3) Modify your treatment approach to include the patient in family sessions when clinically appropriate, or (4) Collect payment directly from the family if the service is not covered. Always inform families about coverage limitations before providing services.
Can I bill 90846 and individual therapy (90834) on the same day?
Yes, if these are truly separate sessions with distinct clinical purposes and separate documentation. For example, you might see a child for individual play therapy in the morning, then meet with the parents in the afternoon. Use modifier 59 or XE if required by the payer to indicate distinct services. However, be aware that some payers may flag or deny same-day claims for review.
How many 90846 sessions can I bill per month?
There is no universal limit. However, many payers have internal utilization guidelines that may trigger review if you bill 90846 frequently. If you are billing multiple family sessions without the patient present each month, be prepared to justify why this frequency is medically necessary. Excessive use of 90846 relative to 90847 or individual sessions may raise red flags.
What if the family member has their own therapist and their own mental health issues?
If the family member has their own mental health needs, those should be addressed by their own therapist, billed to their own insurance. When you bill 90846, the session must focus on your patient's treatment, not the family member's personal mental health concerns. If a family member starts disclosing their own significant mental health issues, you should refer them to their own treatment and refocus the session on how they can support your patient.
Can I use 90846 for telehealth sessions with family members?
Yes, most payers now cover 90846 via telehealth with the same policies as in-person sessions. Use modifier 95 (or GT depending on payer) and the appropriate place of service code (typically 02 for telehealth). Ensure your telehealth platform is HIPAA-compliant and that all participants are in appropriate locations for confidential discussions.
What credentials are required to bill 90846?
The same credentials required for other psychotherapy codes in your state and with each payer: typically licensed psychologists, clinical social workers (LCSW), professional counselors (LPC), marriage and family therapists (LMFT), and psychiatrists. Some payers and Medicaid programs have additional requirements. Medicare does not credential LPCs under traditional Medicare, so check credentialing requirements with each payer.
Key Takeaways
CPT 90846 Summary
- 1.CPT 90846 is for family therapy when the identified patient is NOT present. The session must still focus on that patient's treatment needs.
- 2.Many payers restrict or exclude 90846 coverage. Always verify benefits before providing this service to avoid unexpected denials.
- 3.Documentation is critical. Clearly explain who attended, why the patient was absent, how the session focused on the patient's treatment, and the connection to treatment plan goals.
- 4.Medicare reimburses approximately $121.47 for non-facility settings. Commercial rates are typically 15-40% higher when covered.
- 5.Get proper consent and HIPAA authorizations before sharing patient information with family members or billing for family sessions.
- 6.When the patient can be present, 90847 typically has fewer coverage restrictions and lower denial rates than 90846.
CPT 90846 serves an important clinical purpose. Working with family members is often essential for successful treatment outcomes, especially for children, adolescents, and adults with severe mental illness. However, the billing landscape for this code is more complex than for standard individual therapy.
The key to success with 90846 is preparation: verify coverage before you provide the service, document thoroughly to demonstrate medical necessity, and be prepared to advocate for your clinical decisions if claims are questioned. With proper planning and documentation, you can provide this valuable service while protecting your practice from billing complications.
Need help managing family therapy billing alongside your individual caseload? TheraFocus simplifies the entire process with automated documentation templates, real-time eligibility verification, and claims tracking that alerts you to potential issues before they become denials. See how TheraFocus can streamline your practice.
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The TheraFocus team is dedicated to empowering therapy practices with cutting-edge technology, expert guidance, and actionable insights on practice management, compliance, and clinical excellence.