AI-generated ICD-10 and CPT codes from clinical notes — Medical Coding Online
Psychotherapy CPT Codes (Standalone)
Standalone psychotherapy codes are used by non-prescribing mental health providers (psychologists, LCSWs, LPCs) when the session involves only psychotherapy — no medical E/M component. These codes are time-based.
| CPT Code | Service | Time |
|---|---|---|
| 90832 | Psychotherapy, individual | 30 minutes (16–37 min) |
| 90834 | Psychotherapy, individual | 45 minutes (38–52 min) |
| 90837 | Psychotherapy, individual | 60 minutes (53+ min) |
| 90847 | Family psychotherapy with patient present | 50 minutes |
| 90846 | Family psychotherapy without patient present | 50 minutes |
| 90853 | Group psychotherapy | Per session (not time-based) |
| 90839 | Psychotherapy for crisis — initial 60 min | 30–74 minutes |
| 90840 | Psychotherapy for crisis — add-on | Each additional 30 min |
E/M + Psychotherapy Add-On Codes
Psychiatrists and other prescribers who provide both medication management (E/M) and psychotherapy in the same visit use an E/M code plus an add-on psychotherapy code. The add-on code reflects only the psychotherapy time.
- 90833 — psychotherapy add-on to E/M, 30 min (16–37 min of psychotherapy)
- 90836 — psychotherapy add-on to E/M, 45 min (38–52 min of psychotherapy)
- 90838 — psychotherapy add-on to E/M, 60 min (53+ min of psychotherapy)
- Add-on codes cannot be billed without a primary E/M code
- Document time separately: E/M medical decision-making time vs. psychotherapy time
- Total visit time = E/M time + psychotherapy time combined
Psychiatric Evaluation Codes
Initial psychiatric evaluations use dedicated codes rather than standard E/M office visit codes. These evaluation codes have specific documentation requirements for mental status examination and diagnostic formulation.
| CPT Code | Service | Notes |
|---|---|---|
| 90791 | Psychiatric diagnostic evaluation | No medical services component |
| 90792 | Psychiatric diagnostic evaluation with medical services | For prescribers who include medication assessment |
| 99202–99215 | E/M office visit | Used for follow-up medication management |
| 90885 | Psychiatric evaluation of hospital records | Record review service |
| 90887 | Interpretation of results to family/others | Not a therapy session |
Mental Health Parity and Coverage Requirements
The Mental Health Parity and Addiction Equity Act (MHPAEA) requires insurers to cover mental health and substance use disorder benefits on par with medical/surgical benefits. This affects prior authorization requirements, visit limits, and cost-sharing.
- Parity applies to quantitative limits: visit limits, day limits, cost-sharing
- Parity also applies to non-quantitative limits: prior auth, step therapy, formulary
- Payers cannot require more restrictive prior auth for mental health than for medical services
- Failure to follow parity rules is an increasingly common compliance issue
- Document medical necessity thoroughly — parity does not eliminate clinical criteria
- Substance use disorder treatment is covered under same parity requirements
Documentation Requirements for Mental Health Billing
Mental health claims are among the most frequently audited. Adequate documentation protects the provider and supports medical necessity for continued care.
- Chief complaint and presenting problem at each visit
- Mental status examination findings
- DSM-5 diagnostic impression with ICD-10-CM code
- Treatment plan goals and progress toward goals
- Risk assessment (suicidality, homicidality) at each visit
- Time spent in psychotherapy (required for time-based codes)
- Medication changes and clinical rationale (for prescribers)
How AI Supports Mental Health Coding
AI-powered coding tools assist mental health providers by reviewing clinical notes to identify the correct CPT codes, validate time-based coding requirements, and ensure ICD-10 diagnostic codes are at the highest specificity level.
- Identify correct psychotherapy code from documented session time
- Detect E/M + add-on code combination opportunities for prescribers
- Suggest ICD-10 codes from DSM-5 diagnoses in the note
- Flag incomplete mental status exam documentation
- Validate parity compliance in prior authorization workflows
- Reduce undercoding from providers unfamiliar with add-on code structure
Frequently Asked Questions
- What is the difference between CPT 90791 and 90792?
- CPT 90791 (psychiatric diagnostic evaluation) is for a comprehensive mental health evaluation that includes a clinical interview, mental status exam, and diagnostic formulation — but no medical services component. CPT 90792 adds a medical services component, meaning the evaluating clinician is also assessing and managing medications. 90792 is appropriate for psychiatrists and other prescribers; 90791 is used by psychologists, LCSWs, and non-prescribers.
- How do I code a 45-minute therapy session for a psychiatrist who also manages medications?
- A psychiatrist seeing a patient for both medication management and psychotherapy uses an E/M code (99212–99215 based on medical decision making) plus a psychotherapy add-on code. If the psychotherapy portion was 38–52 minutes, add 90836. Document the time breakdown clearly in the note: how much time was devoted to the E/M portion (medication management) and how much to psychotherapy.
- Can I bill for phone calls or telehealth mental health sessions?
- Yes. Telehealth coverage for mental health expanded significantly after 2020. Use the same CPT codes (90837, 90834, etc.) with the appropriate telehealth Place of Service code (POS 02 for patient at home) and modifier 95 if required by the payer. Telephone-only visits may use telephone E/M codes (99441–99443) but coverage varies by payer.
- How does group therapy billing work?
- Group psychotherapy is billed with CPT 90853 per session, regardless of session length. Each patient in the group receives their own claim for 90853. Group is typically 2 or more patients with a therapist present. The code is not time-based. Documentation should include the names/identifiers of all group members, the topics addressed, and each patient's participation and response.
- What ICD-10 codes are used for common mental health diagnoses?
- Common ICD-10 mental health codes include: F32.1 (major depressive disorder, moderate), F41.1 (generalized anxiety disorder), F43.10 (PTSD, unspecified), F90.0 (ADHD, predominantly inattentive), F31.81 (bipolar II disorder), F20.9 (schizophrenia, unspecified), F10.20 (alcohol use disorder, moderate). Always code to the highest level of specificity available from the clinical documentation.