Frequently Asked Questions CPT Coding and Documentation

Frequently Asked Questions
Coding and Documentation

In 2013 the CPT Psychiatry codes changed significantly, creating an entirely different coding framework. The answers to these FAQs are based on experience thus far with the new coding. Please note that this is not legal advice. Members are advised to seek the advice of attorneys specializing in this area of law for any legal questions.

Why are there now two codes to use for a standard initial psychiatric diagnostic evaluation, 90791 and 90792?

Previously all mental health clinicians use the same initial evaluation codes, 90801 and 90802, even though nonmedical providers could not provide the medical work that was described in those codes. Now, psychiatrists use code 90792, which indicates medical services were provided, while nonmedical providers use 90791, which does not include medical services. Medical services may consist of any medical activities such as performing elements of a physical exam or considering writing a prescription or modifying psychiatric treatment based on medical comorbidities.


Instead of using the previous psychotherapy codes with E/M services (90805, 90807), we now must bill using the appropriate E/M code from the 99xxx series of codes (i.e., 99211, 99212, etc) and a timed add-on code for the psychotherapy. What exactly is an add-on code?

An add-on code is a code that can only be used in conjunction with another, primary code and is indicated by the plus symbol (+) in the CPT manual. The add-on code concept was developed to eliminate the redundancy of work that occurs when you provide two services on the same day (i.e., reviewing a patient’s medical record, greeting the patient). In the new Psychiatry codes there are three different types of add-on codes:

  1. Timed add-on codes to be used to indicate psychotherapy when it is done with medical evaluation and management
  2. A code to be used when psychotherapy is done that involves interactive complexity
  3. A code to be used with the new crisis therapy code for each 30 minutes beyond the first hour. On the claim form, the add-on code is listed as a second code.

What is an E/M code?

The evaluation and management (E/M) codes are found in the first section of the AMA CPT manual. The first two digits of this code set are 99. The E/M codes are generic in the sense that they can be used by all physicians to describe general medical services. Code selection is based on whether the patient is new or established, the setting (outpatient, inpatient, nursing facility, etc.), and on the complexity of the service provided, which is based on the nature of the presenting problem. There are specific documentation requirements when using these codes.

You can download a list of the most frequently used E/M codes as well as information on the documentation requirements for CPT Coding Changes.

Download: Codes and Documentation for E/M


I’d never used the CPT evaluation and management codes before, is there somewhere I can find out about how to use them?

You can download the chapter on E/M coding from the book Procedure Coding for Psychiatrists (the information on the psychiatry codes in this 2011 book is now obsolete, but the information about the E/M codes is current.) The chapter is available here as are a number of webinars dealing with E/M coding. APA also has an online CME course on the CPT code changes available free to members at APA's Learning Center.

View Course


What E/M code is used to indicate the E/M services I provide to patients I see for psychotherapy and E/M for whose sessions I previously coded 90807?

The most basic E/M service provided by a physician for outpatient work with an established patient is 99212. This would most likely be the appropriate code to use when you see a stable patient. There are specific guidelines for selecting E/M codes published by the Centers for Medicare and Medicaid Services, and a link can be found to these guidelines at psychiatry.org/cptcodingchanges. The guidelines mandate elements of history, examination, and medical decision making that must be covered to satisfy the various levels of E/M coding, and you will have to be sure that your documentation fulfills the requirements for 99212 or any other E/M code that you use.

View E/M Templates


What E/M codes do I use when I see a patient in a psychiatric residential treatment center?

The nursing facility services E/M codes are used for a psychiatric residential treatment center (defined as a facility that provides 24-hour therapeutically planned and professionally staffed group living and learning environment). These codes are 99304-99306 for the initial encounter and 99307=99310 for subsequent care.


When I am called in to do a psychiatric consult for a patient in the emergency department, what code should I use?

You can use 90792, which can be used in any setting for a psychiatric diagnostic evaluation with medical services, or you can use one of the outpatient E/M codes that correspond to the complexity of the patient’s presentation. If the patient has not already been seen by another psychiatrist in your practice, you should use one of the new patient E/M codes; and if the patient is not new to your practice, you should use one of the established patient codes.


When I see a patient for a session during which I provide E/M services and psychotherapy, do I document for the time spent for the entire session or just for the time spent providing psychotherapy since I selected the E/M code based on the elements necessary to meet the complexity of the patient’s presentation?

Appropriate documentation requires that you either provide start and stop times or a total time for your face-to-face interaction with the patient. The psychotherapy add-on code you select indicates the approximate length of the psychotherapy.


Can I choose the E/M code on the basis of time spent providing counseling and coordination of care and also bill for psychotherapy using the psychotherapy add-on?

No, if you are doing psychotherapy in conjunction with an E/M service, you must choose the E/M code on the basis of the work performed, NOT on the basis of time spent providing counseling and coordination of care.


In my outpatient practice I often see patients solely for medication management for which previously I previously coded using CPT code 90862. What code replaced 90862?

The typical outpatient 90862 is most similar to E/M code 99213. If the patient you are seeing is stable, and really just needs a prescription refill, code 99212 might be a more appropriate crosswalk. If you have a patient with a very complex situation, you might need to use 99214, a higher level E/M code. The E/M codes have documentation guidelines published by the Centers for Medicare and Medicaid Services (CMS) that explain how to determine which level code to choose. Find more information here.


Are the times listed for the add-on psychotherapy codes in addition to the time spent doing the E/M or is the time spent doing the E/M included in the time listed for the psychotherapy?

The time listed for the psychotherapy add-on code accounts ONLY for the time spent providing psychotherapy. Any time spent providing E/M services should not be included in the psychotherapy add-on time.


I am a solo practitioner and generally see my patients for both E/M and psychotherapy on a weekly basis. Does the E/M code I bill limit the psychotherapy code I can bill?

No. The two services are separate. You code and document for whatever level of E/M is warranted by the patient’s presenting problem that day and select the add-on psychotherapy code based on the length of time of the psychotherapy provided. (The add-on psychotherapy codes are 90833 for 30 minutes, 90836 for 45 minutes, and 90838 for 60 minutes.) Since the current psychotherapy codes are not for a range of time, like the old ones, but for a specific time, the CPT “time rule” applies. If the time is more than half the time of the code (i.e., for 90832 this would be 16 minutes) then that code can be used. For up to 37 minutes you would use the 30-minute code; for 38 to 52 minutes, you would use the 45-minute code, 90834; and for 53 minutes and beyond, you would use 90837, the 60-minute code.


I take no insurance in my practice, but give my patients invoices for my services, which they submit to their insurance companies for reimbursement. I see my patient regularly for psychotherapy along with medical evaluation, and in the past always coded for the visit with 90807. Under the new coding format, the patient is required to submit a bill with the new codes. I will code using 99212 (since almost all my patients are stable and just require minimal E/M) and 90836, the add-on psychotherapy code for 45 minutes of psychotherapy. My question is, with the current CPT codes, am I required to apportion my fee between these two codes? If so, is there a reasonable way to do this?

Most insurers do require you to apportion your fee between the two codes. A reasonable way to do this may be to base how you apportion the fee on the relative value units that Medicare assigns to each of the codes. You can find these RVUs on the APA’s website here under the heading “RVUs.” If you take the total of the RVUs for the two codes you bill and divide that into your total fee, that will give you what your practice’s fee is for 1 RVU. Multiplying this by the RVUs assigned to each code will give you a fee for each code. Many payers base their fee schedules on the RVUs Medicare assigns, so the insurer should have no trouble accepting this approach.


I’m a solo practitioner and still file paper claims, how do I fill out the 1500 form to show I’ve done an E/M service with psychotherapy?

The first service reported is the E/M code, on line 1, and underneath that, on line 2, you write in the add-on code (just the five digits, no plus sign) as a second service. You need to fill out each line completely, including the fee for each service.


I am a child psychiatrist and, in the past, generally billed using one of the interactive psychotherapy codes. What do I use now to indicate the nature of the encounter?

There is an add-on code, 90785, that can be used with diagnostic evaluation or psychotherapy codes to indicate what is referred to as “interactive complexity.” The concept of interactive complexity has was expanded. See the interactive complexity guide developed by the American Academy of Child and Adolescent Psychiatry at psychiatry.org/cptcodingchanges.


What CPT code would be appropriate for a psychiatrist to bill for the evaluation of a patient in the emergency room setting? Would the ER evaluation and management CPT codes (99281-99291) be appropriate if the patient was already seen by a clinical social worker and the clinical social worker is billing for the psychiatric evaluation by using CPT 90791? Or, would the psychiatrist be allowed to bill for CPT code 90792 on the same day the clinical social worker used CPT 90791?

Usually the ER codes would be billed by the ER physician who sees the patient in the ER. The psychiatrist who sees the patient in the ER is doing so as an outpatient consultation. He/she could use the E/M outpatient consult codes (99241-99245) or 90792. (If the patient has Medicare, you can't bill the consult codes, but can use the outpatient E/M new patient codes, 99201-99205, instead, or 90792). If both a social worker and a psychiatrist each did a complete evaluation on a patient, the social worker could bill a 90791 and the psychiatrist a 90792. That said. although you could code this way, it is likely that many payers would question why it was necessary for both clinicians to do an initial evaluation, and they may not be willing to reimburse for both. If the patient is admitted to the inpatient psychiatry service, the psychiatrist would use the initial hospital care E/M codes (99221-99225), which would cover both the consult and initial psychiatric evaluation.


If during an evaluation or a follow-up session, meds are NOT prescribed, but the patient is assessed as to whether meds would be appropriate, can we still consider that an E/M?

Yes, E/M codes describe any manner of medical work and not just the prescribing of medication.


If the psychiatrist sees the patient and does 30 minutes of combined psychotherapy and medication management, and then the patient sees a social worker for 30 minutes of psychotherapy alone, what should they bill?

You would bill the work performed (the appropriate level E/M and the add-on psychotherapy code 90833 for the psychiatrist if the psychotherapy provided took at least 16 minutes; 30 minute psychotherapy code for the social worker). However, it’s important to understand that the payer determines whether or not those codes can be billed on the same day for the same patient.


Do you recommend using the E/M new patient codes or 90792?

You can use either. There may be times, based and the presenting problem and the complexity of the work performed, when a higher level E/M code may be more appropriate.


What is the difference between Psychotherapy with E/M versus E/M with Psychotherapy?

Nothing, they both describe work that includes E/M and psychotherapy services. The current coding format sets the E/M service as primary and the psychotherapy as an addition to the E/M, but that does not necessarily mean that the E/M service was of greater importance than the psychotherapy. Coding this way allows for more accurate accounting of the E/M services provided than did the old codes for psychotherapy that included medical evaluation and management services.


What are the times for the various E/M codes for established patients, and is there any reason you couldn't use the 50% counseling and coordination of care for every follow up visit if it applies?

Correct coding requires that you choose the code that most closely represents the work performed. If more than 50% of your E/M service involves counseling and coordination of care, you can choose the code on the basis of time. You cannot choose the E/M code on the basis of counseling and coordination of care if you also bill a psychotherapy service for the same visit. We must also warn you that consistently billing using high level E/M codes on the basis of counseling and coordination of care may well elicit an audit from Medicare or commercial insurers. In fact, in 2013 Medicare announced that it would be auditing claims for 99215 on the basis of frequency, and there’s no reason to believe this is not continuing.


What constitutes "counseling and coordination of care"?

Counseling, as defined by CPT, is a discussion with a patient and/or family concerning one or more of the following areas:

  • Diagnostic results, impressions, and/or recommended diagnostic studies
  • Prognosis
  • Risks and benefits of management (treatment) options
  • Instructions for management (treatment) and/or follow-up
  • Importance of compliance with chosen management (treatment) options
  • Risk factor reduction
  • Patient and family education

Is thirty minutes now the minimum face-to-face time for psychotherapy with a patient?

Thirty minutes is the shortest timed psychotherapy code. Under the CPT time rule, the 30-minute code can be billed for sessions between 16 and 37 minutes.


Family members of a man with serious mental illness who is not a patient of mine have asked to see me for assistance with navigating the mental health system on behalf of the patient and for help in dealing with the patient at home. I was thinking of using 90846 and calling it Family Therapy without the patient present, but since the patient is not part of my practice this seems questionable.

You are not required to use CPT codes any time you provide medical services, although they are required for billing purposes. Since this is not a service that would be covered by health insurance, there is really no reason to code for this encounter. What is important is that you set the fee with the family in advance, and then provide them with a simple bill for counseling and assistance regarding the family member with mental illness.


What is the difference between a new outpatient E/M visit versus an established outpatient visit?

You only use the new outpatient visit code when this is the first time you’ve ever treated the patient or if it has been more than three years since you or anyone in your practice of the same specialty or subspecialty has seen the patient.


If you are a small psychiatric office and purchasing CPT books, would it be best to purchase AMA CPT along with the ICD-10-CM? Bundles are cheaper.

We would suggest purchasing the AMA CPT book so you have reference to the complete set of coding guidelines developed for the new codes psychiatrists will be using. The DSM uses ICD diagnostic codes, and the DSM-5 provides both the ICD-9-CM codes, which are in use now, and the ICD-10-CM codes, which will go into effect for use in the U.S. in October 2015 so you would not need a separate ICD-10-CM book.


Are there visit note templates that have been developed for psychiatrists to easily check off the bullets necessary for E/M coding?

Templates are available on APA's website.

View E/M Templates


Does code 90792 cover deciding and prescribing medications in the initial session?

Yes, that could be one component of the medical service that differentiates 90792 from 90791.


Are there specific requirements for 90792, and are there other codes for new patients beyond 90791 and 90792?

The documentation requirements for the 90792 are really the same as the documentation for 90801. The only difference is you will want to be sure to list any of the medical work when billing the 90792. Psychiatrists and others who can bill E/M codes may also choose to bill an initial evaluation with the appropriate E/M code.


Is the 90863 code for RNs to use?

90863 is only for use by those few psychologists licensed to prescribe in Louisiana and New Mexico but who, as nonmedical clinicians, are not qualified to bill evaluation and management codes. 90863 is not recognized by Medicare.


Can prescribing psychologists use E/M codes?

No, that is why code 90863 was created.


Where in the CPT code manual does it state that 90863 is for prescribing psychologists only? (I don’t find this reading the information provided on page 559 of the current CPT manual.)

CPT is not provider specific, so this is not specifically stated. However, the rationale behind the development of that code was to accommodate those few psychologists who could prescribe, but by law cannot bill an E/M service.


To purchase a copy of the AMA CPT Manual call the AMA at (800) 621-8335 or go to the AMA online bookstore.

Practice Management HelpLine

If you are an APA member and need assistance with practice management issues, please contact our Helpline.

Contact Us 

Transition to ICD-10

HIPAA-covered entities are required to use ICD-10 codes. View information and guidelines to help you transition to ICD-10 using DSM-5.

Learn More