Psytx w pt w e/m 60 min
CPT 90838 is used when a mental health provider delivers 60 minutes of psychotherapy along with managing medical issues during the same visit. This add-on code is billed with a separate evaluation and management (E/M) code when therapy and medical care happen together.
RVU breakdown
Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High
Billing tips
Always bill 90838 as an add-on code with an appropriate E/M code (99202-99215) on the same claim with modifier 25 on the E/M code, never alone
Impact: Prevents automatic denial - 90838 cannot be paid without a primary E/M service; proper pairing ensures combined payment of $232.25+ per encounter
Document start and stop times for psychotherapy portion separately from E/M medical management, with total psychotherapy time of 52-67 minutes to support 60-minute code
Impact: Prevents downcoding to 90836 (45-minute code, $89.60 non-facility) and supports time-based medical necessity; protects against $33.32 revenue loss per session
Clearly distinguish psychotherapy content (therapeutic techniques, interventions, patient responses) from E/M content (medication review, vitals, physical findings) in documentation
Impact: Reduces audit risk and medical necessity denials; approximately 15-20% of claims face review when services appear bundled or duplicative
Bill facility rate ($109.33) when services provided in hospital outpatient department or on-campus provider-based clinic; non-facility rate ($122.92) for freestanding offices
Impact: Ensures correct payment - billing non-facility rate for facility location triggers recoupment of $13.59 per claim during audits
For patients with crisis intervention needs, consider 90839+90840 instead of E/M+90838 if psychotherapy is crisis-focused rather than medication-focused
Impact: Crisis codes may reimburse higher ($187.91 for first 60 min) and more accurately reflect services; improves compliance and potentially increases revenue by $65+
Verify payer-specific policies for 90838 - some commercial payers require pre-authorization or limit frequency to 1-2 sessions per month
Impact: Prevents denials for service limits; approximately 25-30% of commercial payers have frequency edits that result in denials averaging $122.92 per rejected claim
Applicable modifiers
When to use: Required on the E/M code when billing with 90838 to indicate the E/M service is significant and separately identifiable from the psychotherapy
Reimbursement impact: Essential for payment - without modifier 25 on E/M code, claims will deny as bundled services; ensures full reimbursement of both components
When to use: When psychotherapy and E/M are provided via synchronous telemedicine with audio and video
Reimbursement impact: Maintains full reimbursement at non-facility rate ($122.92) when telehealth is covered; required for many payers post-PHE
When to use: Alternative telemedicine modifier required by some Medicare MACs and commercial payers instead of or in addition to modifier 95
Reimbursement impact: Payer-specific requirement; failure to append when required results in denial; no rate differential
When to use: When services are provided in a substance abuse program setting
Reimbursement impact: May affect rate for certain state Medicaid programs; required for program tracking and compliance
When to use: When clinical psychologist provides services and payer requires distinction from physician services
Reimbursement impact: Some payers reimburse psychologists at 85-100% of physician rate; modifier ensures proper fee schedule application
Common denials
E/M code billed without modifier 25 or modifier 25 not demonstrating significant, separately identifiable service
How to appeal: Submit appeal with documentation highlighting distinct medical decision-making for E/M (medication changes, lab interpretation, physical findings) separate from psychotherapy notes; include time documentation showing both services exceeded typical counseling in E/M; cite CPT guidelines and Medicare's NCCI manual clarifying psychotherapy add-on codes require distinct E/M work
Insufficient psychotherapy time documented - total time less than 52 minutes or time documentation missing/unclear
How to appeal: Provide corrected claim with amended documentation showing start/stop times totaling 52-67 minutes of face-to-face psychotherapy; submit session notes detailing therapeutic interventions throughout time period; reference CPT time ranges and cite that 90838 requires approximately 60 minutes (52-67 min range)
Medical necessity not established for both E/M and psychotherapy on same date - services appear duplicative or bundled
How to appeal: Submit detailed documentation separating medical management (medication side effects, dosage adjustments, physical symptoms) from psychotherapy (specific therapeutic techniques, behavioral interventions, processing); include diagnosis codes supporting both medication management needs and psychotherapy indications; provide treatment plan showing integrated care model
Frequency limits exceeded - payer policy restricts 90838 to specific number of sessions per time period
How to appeal: Request peer-to-peer review with medical director; submit clinical documentation supporting medical necessity for increased frequency due to condition severity, medication changes, or crisis stabilization; provide research/guidelines supporting integrated care frequency for specific diagnosis; pursue retro-authorization if policy allows
Frequently asked questions
What is the difference between CPT 90838 and 90834?
90838 is an add-on code for 60 minutes of psychotherapy provided WITH a separate E/M service on the same day, reimbursing at $122.92. 90834 is a standalone code for 38-52 minutes of psychotherapy without E/M, reimbursing at $107.58. Use 90838 when providing medication management (requiring E/M code) plus psychotherapy; use 90834 for psychotherapy-only sessions.
Can CPT 90838 be billed alone or does it require another code?
90838 cannot be billed alone - it is an add-on code that must be billed with a same-day E/M code (99202-99215 for outpatient visits). The E/M code requires modifier 25 to indicate it is separately identifiable. Billing 90838 without a primary E/M code will result in automatic denial.
How much does Medicare pay for CPT code 90838 in 2025?
Medicare pays $122.92 for 90838 in non-facility settings (private offices) and $109.33 in facility settings (hospital outpatient departments) based on the 2025 Physician Fee Schedule. This payment is in addition to the separate E/M code payment, resulting in combined reimbursement typically exceeding $230 per session.
What modifier is required when billing 90838 with an E/M code?
Modifier 25 must be appended to the E/M code (not to 90838) when billing with 90838. This indicates the E/M service is significant and separately identifiable from the psychotherapy. Without modifier 25, payers will deny the E/M code as bundled with the psychotherapy service.
How many minutes of psychotherapy are required for CPT 90838?
CPT 90838 requires approximately 60 minutes of face-to-face psychotherapy, with the acceptable time range being 52-67 minutes. Documentation must include start and stop times. If psychotherapy time is 38-52 minutes, use 90836 instead; if less than 38 minutes, use 90833.
Can psychiatrists bill 90838 for medication management visits?
Yes, psychiatrists commonly bill 90838 when providing both medication management (billed as E/M code 99212-99215 with modifier 25) and psychotherapy during the same 60-minute session. This integrated approach allows capture of both the medical management and therapeutic intervention components, maximizing appropriate reimbursement for comprehensive psychiatric care.
What is the RVU value for CPT code 90838?
CPT 90838 has a total RVU of 3.8 for 2025, consisting of 2.74 work RVU, 0.93 non-facility practice expense RVU (0.51 facility), and 0.13 malpractice RVU. When multiplied by the 2025 conversion factor of 32.3465, this equals the Medicare payment rates of $122.92 (non-facility) and $109.33 (facility).