Understanding the Basics: Psychiatry and Psychology Coding
Psychiatry and psychology involve the diagnosis and treatment of mental health conditions through a variety of services—including evaluations, psychotherapy, and medication management. These services are provided by both physicians and non-physician providers such as:
- Clinical psychologists
- Nurse practitioners (NPs)
- Clinical nurse specialists (CNSs)
- Physician assistants (PAs)
As long as services are within the scope of a provider's license and training, they are billable using standard CPT codes.
1. When to Use E/M Codes vs Psychotherapy CPT Codes
One of the most common areas of confusion in mental health billing is knowing when to use E/M codes versus psychotherapy codes.
Use E/M Codes When… Use Psychotherapy Codes When…
- The visit includes a medical assessment - The session focuses on therapeutic intervention
- There is medication management involved - No medical services are performed
- The provider performs a physical exam - Time is spent on talk therapy
Tip: If a session includes both medical and therapy components, providers can bill for both—but they must use a psychotherapy add-on code (90833, 90836, 90838) in addition to the E/M code, and ensure documentation supports both services as significant and separately identifiable.
2. CPT Codes for Psychotherapy and How to Use Them
Psychotherapy codes are time-based:
- 90832 – 30 minutes
- 90834 – 45 minutes
- 90837 – 60 minutes
Psychotherapy with medical services (like prescribing or managing medications) requires combining the appropriate E/M code with:
- 90833 – Add-on for 30-minute psychotherapy
- 90836 – Add-on for 45-minute psychotherapy
- 90838 – Add-on for 60-minute psychotherapy
Note: Sessions longer than 90 minutes may be reimbursed with documentation of medical necessity and detailed face-to-face time.
3. Interactive Complexity (90785): When Communication Complicates Care
Interactive Complexity is an add-on code (+90785) used when communication issues significantly impact the visit—such as when a patient is accompanied by a family member, interpreter, or guardian. Examples include:
- Managing high emotional reactivity or language barriers
- Caregiver interference with treatment
- Mandatory reporting discussions (e.g., child abuse)
This code must be used in conjunction with other psychotherapy or psychiatric diagnostic codes—never on its own.
4. Diagnostic Interviews: 90791 and 90792
These codes represent the initial psychiatric diagnostic evaluation, with or without medical services:
- 90791 – No medical services (e.g., by a psychologist)
- 90792 – Includes medical services (e.g., by a psychiatrist or NP)
They are typically billed once at the onset of treatment but may be repeated if:
- There’s a break in treatment (usually 6+ months)
- The patient is hospitalized
- There’s a significant change in mental status
- A second opinion or clarification is needed
5. Group and Family Psychotherapy: What to Know
- 90846 – Family therapy without the patient
- 90847 – Family therapy with the patient
- 90853 – Group therapy
- 90839/90840 – Psychotherapy for crisis (first 60 minutes + each additional 30 minutes)
Do not use family therapy codes for simply gathering a family history or for counseling that is not therapy-focused.
6. How AI-Powered Clinical Assistants Can Help
Clinical AI assistants are transforming psychiatric documentation and billing. Here’s how:
- Automated note generation using speech recognition and contextual AI
- Smart CPT suggestions based on documentation content and session length
- Prompts for add-on codes like 90785 when applicable scenarios are mentioned
- Compliance checks to ensure documentation meets Medicare and commercial payor standards
- Time tracking and reminders to support accurate coding for psychotherapy durations
Some systems even automatically separate E/M and psychotherapy elements from a single session note to support billing for both—something that historically required extra manual effort.
7. Billing and Documentation Best Practices
- Always document time spent face-to-face with the patient when billing time-based codes
- Clearly separate medical and therapy components when billing both
- Justify the use of crisis codes or extended time codes with detailed clinical reasoning
- Use the correct site-of-service modifier where applicable (e.g., G0017 and G0018 outside of an office setting)
Streamline Psychiatry Documentation and CPT Coding with AI-Powered Automation
Accurate medical billing and time-dependent CPT code selection are critical in psychiatry and psychology—but they can also be time-consuming and error-prone. That’s where AI clinical assistants like mdhub come in. Designed specifically for mental health professionals, mdhub automates session documentation and intelligently selects the correct CPT codes—all based on real-time session details.
By reducing administrative burden and improving coding accuracy, mdhub helps providers stay compliant, increase reimbursement, and spend more time focused on patient care.
👉 Schedule a free demo to see how mdhub’s AI platform can transform your clinical workflow and billing processes.
