CPT Code 90836: Psychotherapy, 45 Minutes with E/M Service

What is psychotherapy, 45 minutes with evaluation and management service (CPT 90836)?

CPT 90836 describes a 45-minute psychotherapy session provided in conjunction with an evaluation and management (E/M) service on the same date. This code is used when the same physician or other qualified professional performs both medical management (e.g., prescribing or adjusting medications, reviewing labs) and a psychotherapy session.

The psychotherapy must last at least 38 minutes, involve evidence-based therapeutic techniques (e.g., CBT, interpersonal therapy), and address emotional, behavioral, or cognitive disorders. CPT 90836 is typically used by a psychiatrist, a clinical nurse specialist, or another qualified health care professional who delivers integrated care.

CPT code 90836 documentation requirements

When it comes to billing for therapy sessions, it's key to make sure your documentation matches the CPT code. If you're using CPT code 90836, there are a few specific things you’ll want to double-check before you submit your notes.

Here’s what you need to include for CPT code 90836:

• Clearly document that psychotherapy lasted at least 38 to 52 minutes.
• Note the medical management or evaluation and management (E/M) tasks you performed, like medication adjustments or reviewing labs.
• Describe the specific therapeutic interventions used (e.g., CBT techniques, supportive therapy, etc.).
• Document how the patient responded to the interventions during the session.
• Include details about the patient’s current symptoms, progress, or challenges.
• Show that the psychotherapy and E/M service were both medically necessary for the patient’s condition.
• Always sign the note and include your professional credentials.

Making sure your notes hit all these points helps with clean billing and protects you in case of audits down the road.

CPT code 90836 billing guidelines

Good coding guidance makes billing CPT code 90836 easier and saves you a lot of future cleanups. If you're looking for clear direction, here’s what you need to know to get it right the first time:

• Document psychotherapy time separately from the E/M service time since 90836 is a time-based code, and the psychotherapy time must stand alone.
• Clearly show that psychotherapy and E/M services are separately identifiable services in the medical record.
• If using the interactive complexity code 90785, make sure it’s only billed when communication difficulties are present and that time and complexity are fully documented. Do not bill the interactive complexity code if the patient cannot communicate by any means.
• Remember that prolonged services codes cannot be billed alongside 90836 when psychotherapy is performed with an E/M service.
• Confirm first private insurance requirements since they might have additional coding guidance for CPT add-on codes like 90836.

Following solid coding guidance not only protects your billing but also shows the true value of the service performed for your clients.

Other related CPT codes

Psychotherapy codes with no medical evaluation

• 90832: Psychotherapy, 30 minutes with patient
• 90834: Psychotherapy, 45 minutes with patient
• 90837: Psychotherapy, 60 minutes with patient

Group therapy codes

• 90853: Group psychotherapy (other than of a multiple-family group)
• 90846: Family psychotherapy (without the patient present), 50 minutes
• 90847: Family psychotherapy (conjoint psychotherapy) (with patient present), 50 minutes
• 90849: Multiple-family group psychotherapy

Psychotherapy crisis codes

• 90839: Psychotherapy for crisis; first 60 minutes
• 90840: Psychotherapy for crisis; each additional 30 minutes (list separately in addition to code for primary service)