CPT Code 90838: Psychotherapy, 60 Minutes with E/M

CPT 90837 is psychotherapy alone (60 minutes), without medical evaluation and management. CPT 90836 (45 minutes) and 90838 (60 minutes) are add-on codes that combine psychotherapy and E/M services performed by the same provider in the same session.

Not all mental health providers can use this code, and psychologists cannot use it either. Typically, CPT 90838 includes medical evaluation or medication management, which psychologists are not licensed to perform. This code is primarily used by psychiatrists, psychiatric nurse practitioners, or other mental health professionals who integrate medical management into mental health treatment.

Yes. You can bill 99214 (an E/M service) and 90838 together if the documentation clearly demonstrates that a separate, distinct medical evaluation and management service was performed in addition to psychotherapy lasting at least 53 minutes. Use Modifier 25 with 99214 to indicate the distinct E/M service.