How to use CPT code 90836
Code 90836 represents an add-on for 38-52 minutes of psychotherapy with an E/M code.
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How to use CPT code 99212
How to use CPT code 99215
Billing and coding
The 13 most common psychiatry CPT codes (and how to use them)
Understand the ins and outs of CPT codes to help make documentation and billing more efficient — and give you more time to focus on other areas of your practice.
Your work isn’t finished when your patient leaves your office or signs off your telehealth appointment. If you bill insurance, then you’re also responsible for appropriately documenting your patients’ visits. A large part of billing includes understanding Current Procedural Terminology (CPT) codes, which healthcare providers — including psychiatrists — use to describe their services.
There’s no way around it: The process of documentation and billing can be time-consuming. Save time (and stress) with the guide, which outlines the most common psychiatry CPT codes you’ll use to document appointments and bill insurance.
It’s important to use the code that most accurately reflects the time you spent with the patient to treat their condition, and ensure that documentation for the session supports the chosen code.
Diagnostic, evaluation, intake services
When you first start seeing a new patient, you’ll schedule an initial intake appointment to properly diagnose them and evaluate their mental and medical status so you can appropriately treat them. You’ll likely use one of the below codes to do so:
- 90792 – Psychiatric Diagnostic Evaluation With Medical Services: The most common code used for intake appointments, 90792 represents a mental health appointment that involves an evaluation and diagnosis, along with medical services (which include an exam, prescribing, or evaluating existing medication). For that reason, it can only be used by psychiatrists, psychiatric nurse practitioners, and clinical psychologists.
- 90791 – Psychiatric Diagnostic Evaluation: It’s less common for psychiatrists to use 90791 because it doesn’t include a core component of psychiatry, the medical services component. For that reason, it’s primarily used by counselors, social workers, and marriage and family therapists.
Evaluation and management (E/M) services
This category of CPT codes represents the crux of a psychiatrist’s work: office visits for evaluation and management (E/M) services. In the behavioral health realm, this group of codes may encompass any of the following medical services:
- Clinical interview
- Interpreting symptoms
- Forming a diagnosis
- Completing a physical or mental status exam
- Medical decision-making
- Prescribing
- Ordering labs or other tests
The most common E/M codes psychiatrists use include:
New patient visits
- 99202 – Office or Other Outpatient Visits for the Evaluation and Management of a New Patient: Code 99202 represents an E/M appointment with a new patient lasting 15-29 minutes.
- 99203 – Office or Other Outpatient Visits for the Evaluation and Management of a New Patient: Code 99203 represents an E/M appointment with a new patient lasting 30-44 minutes.
- 99204 – Office or Other Outpatient Visits for the Evaluation and Management of a New Patient: Code 99204 represents an E/M appointment with a new patient lasting 45-49 minutes.
- 99205 – Office or Other Outpatient Visits for the Evaluation and Management of a New Patient: Code 99205 represents an E/M appointment with a new patient lasting 60-74 minutes.
Established patient visits
- 99212 – Established Patient Office or Other Outpatient Visit: Code 99212 represents an E/M appointment with an established patient lasting 10-19 minutes.
- 99213 – Established Patient Office or Other Outpatient Visit: Code 99213 represents an E/M appointment with an established patient lasting 20-29 minutes.
- 99214 – Established Patient Office or Other Outpatient Visit: Code 99214 represents an E/M appointment with an established patient lasting 30-39 minutes. This longer visit usually includes medical decision making in more complex cases.
- 99215 – Established Patient Office or Other Outpatient Visit: Code 992125 represents an E/M appointment with an established patient lasting 40-54 minutes. This longer visit usually includes medical decision making in more complex cases.
It’s important to note that these codes can’t be combined with the diagnostic/evaluation codes 90792 or 90791. They can be billed alone or include add-on codes for psychotherapy, which are outlined below.
Psychotherapy services
If you also provide psychotherapy services in addition to evaluation and management — which may include providing non-pharmaceutical coping skills for your patients’ symptoms — you can add on psychotherapy codes in your documentation. Due to the nature of a psychiatrist’s training and specialty, it’s unlikely you’d provide psychotherapy alone without an E/M element.
Psychotherapy codes are add-on codes defined by time. You may use any of the below codes in conjunction with E/M codes:
- 90833 – Evaluation and Management with 30 Minutes Psychotherapy: Code 90833 represents an E/M appointment with 16-37 minutes of psychotherapy.
- 90836 – Evaluation and Management with 45 Minutes Psychotherapy: Code 90836 represents an E/M appointment with 38-52 minutes of psychotherapy.
- 90838 – Evaluation and Management with 60 Minutes Psychotherapy: Code 90838 represents an E/M appointment with 53 minutes or more of psychotherapy.
No matter which CPT codes you use, be sure to include all the applicable codes in a single claim when you file — along with the appropriate documentation that supports the CPT code — for more efficient claim approval and reimbursement for services rendered.
This document is intended for educational purposes only. It is designed to facilitate compliance with payer requirements and applicable law, but please note that the applicable laws and requirements vary from payer to payer and state to state. Please check with your legal counsel or state licensing board for specific requirements.
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Billing and coding
How to use CPT code 90836
How to use CPT code 99212
Code 99212 represents an existing patient appointment that’s at least 10 minutes in duration.
How to use CPT code 99215
Code 99215 represents an existing patient appointment that’s at least 40 minutes in duration.