Direct Answer
Psychiatry billing involves a unique code structure where psychiatric evaluations and psychotherapy services have their own code families (90791–90899), and where the combination of E&M and psychotherapy services in the same visit requires careful use of add-on codes. The 2013 psychotherapy code restructuring — moving from time-based codes to the current "add-on" model — created confusion that still affects billing accuracy today. Understanding when to use psychiatric evaluation codes vs. E&M, how to correctly add psychotherapy to an E&M visit, and how mental health parity laws affect payer obligations is essential for accurate behavioral health revenue cycle management.
Table of Contents
Psychiatric Evaluation Codes
Psychiatric evaluations have dedicated codes separate from E&M: 90791 (psychiatric diagnostic evaluation — without medical services); 90792 (psychiatric diagnostic evaluation — with medical services, including prescribing or psychopharmacologic consultation). The key distinction: 90791 is used when the evaluation is primarily diagnostic and does not include prescribing or medical management (performed by psychologists, licensed clinical social workers, or psychiatrists when medical services are not included); 90792 adds the medical services component (appropriate when the evaluating provider is a prescriber and medical management is part of the evaluation). These codes are not subject to the 2021 E&M guideline changes — they have their own documentation requirements separate from the office E&M framework. The psychiatric evaluation documentation typically includes: reason for referral; psychiatric history; mental status examination; DSM-5 diagnosis; risk assessment; treatment plan and recommendations. Re-evaluations or follow-up visits that include diagnostic re-assessment may also use 90791/90792 when the visit constitutes a new evaluation rather than a follow-up management visit.
Psychotherapy Codes
Psychotherapy codes are time-based — the specific code is determined by the duration of the psychotherapy service: 90832 (psychotherapy, 30 minutes — 16–37 minutes); 90834 (psychotherapy, 45 minutes — 38–52 minutes); 90837 (psychotherapy, 60 minutes — 53+ minutes). These codes are used when psychotherapy is the sole service provided (no E&M component). Family psychotherapy codes: 90846 (family psychotherapy without patient present — 26+ minutes); 90847 (family psychotherapy with patient present — 26+ minutes); 90849 (multiple-family group psychotherapy). Group psychotherapy: 90853 (group psychotherapy — other than multiple-family group, per session). Crisis psychotherapy: 90839 (psychotherapy for crisis, first 60 minutes); 90840 (each additional 30 minutes — add-on). The time documented in the record must support the code billed — document the start and end time of the psychotherapy session. For telephone psychotherapy: 98966–98968 (for non-physician QHPs); 99441–99443 (for physicians) — time-based telephone service codes. Post-COVID, many payers have expanded telehealth coverage for behavioral health to be permanent — verify each payer's current telehealth behavioral health policy.
E&M Plus Psychotherapy
When a psychiatrist (or other prescribing mental health provider) provides both E&M services (medication management) and psychotherapy in the same visit, the billing model is: bill the E&M code for the medication management portion + a psychotherapy add-on code for the psychotherapy portion. The psychotherapy add-on codes: 90833 (psychotherapy add-on, 30 minutes — 16–37 minutes of psychotherapy in addition to E&M); 90836 (psychotherapy add-on, 45 minutes — 38–52 minutes of psychotherapy in addition to E&M); 90838 (psychotherapy add-on, 60 minutes — 53+ minutes in addition to E&M). Example: a 45-minute psychiatric follow-up visit where 20 minutes is medication management E&M and 25 minutes is psychotherapy is billed as 99213 or 99214 (E&M based on medical decision-making) + 90833 (30-minute psychotherapy add-on). The add-on code captures the psychotherapy value in addition to the E&M — it represents real additional work done in the same session. Documentation must delineate the time spent on E&M components vs. psychotherapy to support both the E&M level and the add-on code.
Interactive Complexity and Other Add-Ons
Interactive complexity add-on code 90785 (interactive complexity — add-on) can be used when the psychotherapy session involves one or more specified complicating factors: use of play equipment or other physical aids to communicate therapeutically with a patient who cannot adequately use conventional verbal/symbolic communication; interpretation (language) services; involvement of third parties (guardians, parole officers, social services) whose relationship with the patient changes the nature of the encounter; barriers to engagement or treatment because of comorbid conditions. This add-on is reported with the primary psychiatric service code. The factors that justify 90785 must be documented in the session note. Psychological testing: 96130–96146 cover psychological and neuropsychological testing administration, scoring, and interpretation — see the neurology billing guide for detail on these codes. Crisis services: the 90839/90840 crisis psychotherapy codes require documentation that the patient presented in crisis — a genuine psychiatric crisis requiring specific crisis intervention techniques, not just a difficult or emotionally intense session.
Mental Health Parity and Telehealth
The Mental Health Parity and Addiction Equity Act (MHPAEA) requires that group health plans providing mental health and substance use disorder (MH/SUD) benefits must provide those benefits on terms no more restrictive than the predominant terms for comparable medical/surgical benefits. This means: payers cannot impose higher cost-sharing (copays, deductibles) for mental health visits than for comparable medical visits; payers cannot impose visit limits or prior authorization requirements on mental health that don't apply to analogous medical benefits; payers cannot use stricter medical necessity criteria for mental health coverage. MHPAEA parity violations are an active enforcement area — practices that document payer denials of mental health services for reasons that would not apply to medical services can support parity complaints. Telehealth for behavioral health: post-COVID, many states have enacted permanent telehealth parity laws specifically requiring commercial payers to cover behavioral health telehealth on the same terms as in-person. The audio-only (telephone) expansion for mental health is particularly important — many rural and elderly patients access mental health services primarily via phone. Verify each state's current telehealth behavioral health parity requirements.
FAQ
Can psychologists (PhDs) bill E&M codes, or are they limited to psychotherapy codes?
Psychologists (PhDs) are not physicians and traditionally cannot bill E&M codes (99202–99215) independently — those codes have a medical management/prescribing component in their scope that is outside a non-prescribing psychologist's scope of practice. Psychologists bill using the psychiatric evaluation codes (90791 — without medical services) and psychotherapy codes (90832–90853, 90839–90840). Some states have expanded prescriptive authority for psychologists — in those states and for those licensed psychologists with prescriptive authority, E&M billing may be appropriate. The add-on model for E&M + psychotherapy (90833/90836/90838) is primarily used by psychiatrists and other prescribing providers who provide both medical management and psychotherapy in the same session. Psychologists who provide psychotherapy alongside a physician's E&M in a collaborative care model have a specific billing framework separate from the psychiatrist-only add-on model. Collaborative care management codes 99492/99493/99494 cover integrated behavioral health services in primary care settings — a growing billing area for psychologists embedded in primary care practices.
How should practices handle billing for no-show or cancelled appointments in psychiatry?
Medicare and most commercial payers do not reimburse for no-show appointments or cancellations where no service was rendered — there is no CPT code for a missed appointment. Practices can charge patients a no-show fee as a practice policy, but this fee cannot be charged to Medicare or other insurance — it is a private-pay fee between the practice and the patient. The no-show fee should be disclosed to patients in advance (typically in the financial consent/patient agreement) and applied consistently. For psychiatry specifically, a nuanced approach to no-show policies is clinically appropriate — some patient populations (particularly those with severe mental illness) may have higher no-show rates related to their condition. Charging no-show fees for Medicaid patients is typically prohibited under Medicaid participation agreements. The administrative burden of no-show fee collection should be weighed against the practice's ability to fill the appointment slot with another patient — often the revenue recovery from filling the slot exceeds the no-show fee revenue, making same-day scheduling and waitlist management more impactful than aggressive no-show fee enforcement.
Behavioral Health Billing That Captures Full Value
Valiant Lifecare's behavioral health billing team manages the psychiatry E&M/psychotherapy billing framework, add-on code compliance, parity law documentation, and telehealth billing — ensuring mental health practices capture appropriate reimbursement for every service rendered.
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