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

What is CPT code 90838?

CPT code 90838 is an add-on psychotherapy code that mental healthcare providers use when delivering psychotherapy along with an evaluation and management (E/M) service during the same patient encounter. Typically lasting 60 minutes, this code reflects psychotherapy services that significantly addresses mental health issues, such as anxiety disorders, depression, or complex psychiatric conditions, in combination with medical evaluation and medication management. This code cannot

Psychiatrists and psychiatric nurse practitioners most commonly use CPT 90838 when both therapeutic counseling and medical assessment are clinically necessary during one session, enabling comprehensive mental health care and effective symptom management.

CPT code 90838 is strictly for individual psychotherapy sessions and is not appropriate for billing group therapy or group psychotherapy. All treatments provided, including psychotherapy and E/M components, must be thoroughly documented in the patient’s medical record to support accurate billing.

CPT code 90838 documentation requirements

Complete and accurate documentation ensures medical necessity and compliance with proper coding practices for mental health services.

Total duration of session and psychotherapy time

Clearly document the total face-to-face duration of the session. Detail how much of the total session was dedicated specifically to therapeutic interventions, ensuring psychotherapy comprises the majority of the encounter.

Description of therapeutic techniques used

Record the therapeutic methods or interventions used, such as cognitive-behavioral therapy (CBT), psychodynamic approaches, supportive therapy, or other recognized psychotherapy techniques. Including these details helps validate clinical necessity and guides future mental health care.

Patient response and clinical observations

Include observations on the patient’s response to treatment, noting emotional and behavioral changes, improvements, challenges, or adverse reactions. These clinical observations substantiate ongoing treatment decisions and progress evaluations.

E/M components documented separately

Clearly document the E/M elements separately from the psychotherapy portion, such as mental status examinations, updates to medical history, medication reconciliation, and adjustments to treatment plans. Separating these components is essential for accurate billing and compliance.

Rationale and clinical necessity for dual services

Explicitly document the clinical rationale supporting the necessity of performing both psychotherapy and an evaluation and management service during the same session. Demonstrating medical necessity for dual services supports accurate billing and payer compliance.

CPT code 90838 billing guidelines

Proper billing practices are essential to secure reimbursement and comply with coding regulations when reporting psychotherapy codes like 90838.

Combine psychotherapy with E/M services only when medically necessary

Bill CPT 90838 when psychotherapy (53+ minutes) and a significant, separately identifiable evaluation and management service (such as CPT codes 99202–99215) occur in the same visit. Ensure both services are clearly documented to reflect distinct clinical purposes.

Append modifier 25 to the E/M service

When billing 90838, always report the associated E/M code (e.g., 99213, 99214) separately, appending Modifier 25 to indicate that the E/M service was distinctly identifiable from psychotherapy. Modifier 25 signals to payers that two distinct services occurred, supporting accurate reimbursement.

Typically billed by psychiatrists and psychiatric nurse practitioners

CPT 90838 is typically reserved for psychiatrists and psychiatric nurse practitioners due to the inclusion of medical evaluation and medication management. Psychologists and licensed social workers generally do not use this code because it incorporates medical management beyond their scope.

Verify payer coverage and requirements

Some payers may bundle or require additional documentation for CPT 90838. Always verify specific payer policies and ensure documentation clearly supports medical necessity to avoid claim denials or delays.

Other relevant CPT codes

• 90837 – Psychotherapy, 60 minutes (without E/M)
• 90833 – Psychotherapy, 30 minutes with E/M service
• 90836 – Psychotherapy, 45 minutes with E/M service
• 99213–99215 – Office or other outpatient evaluation and management services
• 90791 – Psychiatric diagnostic evaluation