Code 90838 represents an add-on for at least 53 minutes of psychotherapy with an E/M code.
December 9, 2024
9 min read
The 90838 code is an add-on therapy code used by prescribing providers. For other E/M codes, visit this overview.
Code 90838 represents an add-on for 53 or more minutes of psychotherapy to a new patient or existing patient E/M code. This code can’t be billed by itself or with a non-E/M code. When you add to an E/M code, the E/M code has to be billed based on medical decision-making, not time.
90838 is a prescriber code, so it’s most commonly used by psychiatrists and nurse practitioners.
This is is how the American Medical Association defines 90838 in the official CPT codebook:
CPT code 90838:
60 minutes with patient when performed with an evaluation and management service
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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.
Code 90838 documentation has specific guidelines as a therapy add-on code. It should be in the same note as the E/M code, but in a separate section.
The example note below includes documentation for a 90838 session, because the client displays moderate risk with two stable illnesses requiring moderate levels of MDM associated with illness monitoring, ongoing support, and prescription treatment.
The 60 minutes spent on psychotherapy during the encounter falls within the 53 or more minutes range required for reporting add-on CPT code 90838.
Patient Name: Sallie Mae
Date of Service: 04/16/2023
Patient DOB: 06/29/1945
Appointment Time: 11:00am-12:15pm
Place of Service: Patient was located at their home at 123 Main St Anywhere US 12345
Provider was located at their office: 456 Storybook Ln Hollywood CA 96852
This session was provided via a HIPAA compliant interactive audio/video platform. The patient consented to this telemedicine encounter.
The total time I spent caring for this patient today was 75 minutes which included: interviewing the client, documenting, reviewing the patient's responses to questionnaires, discussing treatment plans, coordinating care, prescription management and counseling the client on managing her mental health.
Chief Complaint: Follow-up consultation for a 77-year-old female, presenting with exacerbation of symptoms related to her chronic mental health conditions.
History of Present Illness: Sallie reports a recent escalation in symptoms associated with both depression and post-traumatic stress disorder (PTSD). She describes increased feelings of sadness, hopelessness, and intrusive thoughts related to traumatic experiences. Sleep disturbances, including nightmares and insomnia, have intensified, impacting his overall functioning and ability to maintain daily routines. Sallie acknowledges heightened irritability and difficulty concentrating at work, further exacerbating her distress
Psychosocial History: Married, 2 children at home, works in office, college graduate, parent good relationship
Behavioral Health/Psychiatric History: therapy previously, no hospitalizations
Medical History: High BP, knee surgery
Current Medications: prazosin 1 mg at bedtime, sertraline 100 mg 1xday
Allergies: NKA
Exam: Vital signs stable. Patient displays signs of psychomotor agitation and hyperarousal. Mood observed as consistently low, with increased anxiety evident during the examination.
ROS:
Constitutional: denies unexplained weight loss or weight gain, fever, night sweats HEENT: denies
Cardiovascular: denies
Respiratory: denies
Neurological: denies
Psychiatric: depression
Gastro: denies
Musculoskeletal: denies
Tests: The patient's score on PHQ-9 was 9 suggestive of mild depression. The patient's score on GAD-7 was 7 suggestive of mild anxiety.
MSE: Orientation: Alert & Orientedx3
Appearance: neatly dressed, appears stated age
Speech: Normal
Perception: Normal
Thought content: logical
Insight/judgment: Normal
Cognition: Normal
Substance Abuse Assessment: 2-3 drinks alcohol/month, nonsmoker, no recreational drug use
Risk Assessment: No SI/HI, overall risk is moderate. Safety plan has been established.
F33.2 Major depressive disorder, recurrent, with exacerbation:
Sallie presents with recurrent episodes of major depressive disorder, currently experiencing an exacerbation. Her symptoms meet the DSM-5 criteria for Major Depressive Disorder, as follows:
Sallie has a chronic history of post-traumatic stress disorder, now exacerbated by recent stressors. Her symptoms meet the DSM-5 criteria for PTSD, as follows:
1. Adjustment Of Medication Regimen:
2. Referral for intensive psychotherapy:
Implement weekly sessions of prolonged exposure therapy (PET) to address PTSD symptoms and facilitate emotional processing of traumatic experiences.
3. Safety monitoring: Personalized safety plan was developed to address potential suicidal ideation or self-harm behaviors.
4. Follow-up and next steps:
Behavior(s) addressed: sadness, hopelessness, and intrusive thoughts related to traumatic experiences
Interventions used: supportive therapy and utilized CBT techniques to reframe cognitive distortions
Response: Fair, minor reduction in sadness and intrusive thoughts
Goal/Plan: Sallie will decrease frequency and intensity of intrusive thoughts and episodes of sadness by utilizing coping strategies, referral to PET therapist for more in-depth work on trauma-related issues
Electronically signed by,
[Provider name, Credentials, Date signed]
__________________________________________________________________________________________
Rationale information is not required in your note; it is provided for educational purposes only.
Number and Complexity of Problems Addressed: 2 Chronic illnesses with exacerbation
Data Reviewed/Analyzed: PHQ-9, GAD-7
Risk: Moderate: Prescription drug management
Rationale: The client displays High number & complexity of problems with two chronic illnesses with exacerbation, Low amount of data reviewed, and Moderate risk for prescription management. A total of 42 minutes of psychotherapy was provided during the session.
Level of MDM: Moderate CPT Code Selected: 99214 + 90838
Reimbursement rates for sessions billed with 90838 will vary based on the specific payer contract, your geographic location, and type of therapy license. Headway providers can check the portal for rates with each insurance provider.
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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This content is for general informational and educational purposes only and does not constitute clinical, legal, financial, or professional advice. All decisions should be made at the discretion of the individual or organization, in consultation with qualified clinical, legal, or other appropriate professionals.
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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.
Headway strives to simplify billing insurance so you can focus on providing care. Read our comprehensive guide to mental health billing.
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.
