Billing Tips for Psychotherapy with Evaluation & Management (E/M)

To be paid correctly for a psychotherapy visit with E/M, certain documentation is required. The psychotherapy and medical components of the notes must be significant and separately identifiable. The Comprehensive Error Rate Testing (CERT) contractor reviews medical records on samples of processed claims. Review findings may include elements necessary to improve documentation and ensure the service for psychotherapy and E/M was supported.

Psychotherapy with an eligible E/M service can be reported using an E/M code plus a psychotherapy add-on code when performed on the same day (review CMS NCCI add-on codes).

  • E/M key components - history, examination, and medical decision-making
  • Must be separately identifiable from psychotherapy service
  • 90833 - Psychotherapy, 30 minutes with patient when performed with E/M
  • 90836 - Psychotherapy, 45 minutes with patient when performed with E/M
  • 90838 - Psychotherapy, 60 minutes with patient when performed with E/M

To bill psychotherapy on the same day as an E/M visit:

  • Two services must be significant and separately identifiable
  • Focus is on patient with their presence required for all or majority of time
  • Time spent for each service must be clearly documented in the medical record by number of minutes, or start and stop times, for each service.

The CPT code book provides the following information on these codes:

  • Type and level of E/M service selected based on medical decision-making
  • Time spent on E/M activities not used to report time for psychotherapy
  • Time may not be used as basis of E/M code selection
  • Prolonged services may not be reported when psychotherapy with E/M services are reported

Resources

Last Updated Nov 27 , 2024