CPT Code 90838: When and How to Maximize Reimbursement for Therapists

Accurate billing is crucial for ensuring you receive proper compensation for the time and care you provide. If you’re offering longer psychotherapy sessions, understanding and using CPT code 90838 is key to maximizing reimbursement.

In this article, we’ll dive into the specifics of CPT code 90838—explaining when and how to use it effectively in your practice. With these insights, you can streamline your billing process and ensure you’re getting reimbursed fairly for your services.

What is CPT Code 90838?

CPT code 90838 stands for a 60-minute psychotherapy session with a patient and/or family member, performed alongside an evaluation and management service. Use this code to bill for a visit that combines both medical evaluation and management with psychotherapy.

When to use CPT Code 90838

CPT code 90838 applies when you provide psychotherapy along with medical evaluation and management services in a single session lasting about 60 minutes. This code suits situations where both psychotherapy and medical assessment are needed for thorough patient care. Some typical scenarios where CPT code 90838 fits include:

• Patients with both medical and mental health conditions: When treating individuals with physical and psychological symptoms, such as chronic pain and depression, CPT code 90838 allows you to address both aspects of their health in one visit.
• Assessing medication side effects: If a patient experiences psychological side effects from a medication prescribed for a medical condition, you can use CPT code 90838 to evaluate their mental state and adjust their treatment plan as needed.
• Evaluating mental health alongside a medical diagnosis: When a patient receives a new medical diagnosis, such as cancer or a chronic illness, you may use CPT code 90838 to assess their emotional response and coping strategies, while also addressing their medical concerns.

To use CPT code 90838, the session must involve a significant level of medical evaluation and management, such as reviewing the patient's history, conducting a physical examination, or making treatment decisions based on medical findings. The psychotherapy component should be distinct from the medical evaluation and management, focusing on the patient's mental health, emotional well-being, and behavioral patterns.

When not to use CPT Code 90838

While CPT code 90838 helps in billing psychotherapy with medical evaluation and management, there are situations where it's not suitable. Avoid these common mistakes to ensure correct coding and reimbursement:

• Insufficient medical evaluation and management: CPT code 90838 demands a significant level of medical assessment. If the session primarily involves psychotherapy without substantial medical evaluation and management, opt for a different code, such as 90834 for a 45-minute psychotherapy session.
• Separate services on the same day: If you offer psychotherapy and medical evaluation and management as distinct services on the same day, bill them separately using the appropriate codes (e.g., 90834 for psychotherapy and 99213 for evaluation and management) rather than using CPT code 90838.
• Group therapy sessions: CPT code 90838 is not meant for group therapy. Instead, use code 90853 for group psychotherapy.
• Family therapy without the patient present: For family psychotherapy without the patient, use code 90846. CPT code 90838 requires the patient's presence for the majority of the session.
• Medication management only: If a session focuses solely on medication management without psychotherapy, use the appropriate evaluation and management code (e.g., 99213) instead of CPT code 90838.

Make sure to document the services provided thoroughly, clearly distinguishing between the psychotherapy and medical evaluation and management components. Accurate documentation is important for justifying the use of CPT code 90838 and avoiding claim denials or audits.

Requirements and Billing Criteria for CPT Code 90838

To avoid claim denials and ensure compliance when using CPT code 90838, it's important to meet the necessary documentation and billing criteria. Here are the key requirements:

• Significant medical evaluation and management: Include a substantial level of medical assessment in the session, such as reviewing the patient's history, conducting a physical exam, or making treatment decisions based on medical findings.
• Distinct psychotherapy component: Keep the psychotherapy portion separate from the medical evaluation and management, focusing on the patient's mental health, emotional well-being, and behavioral patterns.
• Time-based coding: Use CPT code 90838 for sessions lasting approximately 60 minutes. Document the total time spent with the patient, ensuring that the majority of the session involves the patient's presence.
• Clear documentation: Maintain thorough and accurate records, clearly distinguishing between the medical evaluation and management and psychotherapy components. Include the reason for the encounter, relevant history, physical examination findings, diagnosis or clinical impression, rationale for ordering diagnostic or ancillary services, and the plan for care.
• Legibility and completeness: Ensure that the medical record is legible and complete, with all relevant information clearly documented. Each entry should be dated and signed by the healthcare provider.
• Support for CPT and ICD-10-CM codes: The documentation in the medical record must support the CPT and ICD-10-CM codes reported on the health insurance claim form or billing statement.

Keep up with annual CPT code updates and make sure your documentation practices align with these changes to maintain accurate and compliant coding. Regularly review your billing processes, and seek guidance from coding experts or professional organizations when needed.

Common Pitfalls to Avoid for CPT Code 90838

When working with CPT code 90838, keep these frequent errors and misconceptions in mind to ensure accurate billing and compliance:

• Insufficient medical evaluation and management: CPT code 90838 requires a significant amount of medical assessment. If the session mainly involves psychotherapy without substantial medical evaluation and management, consider using a different code, such as 90834 for a 45-minute psychotherapy session.
• Separate services on the same day: If you provide psychotherapy and medical evaluation and management as distinct services on the same day, bill them separately using the appropriate codes (e.g., 90834 for psychotherapy and 99213 for evaluation and management) instead of using CPT code 90838.
• Incorrect time-based coding: Use CPT code 90838 for sessions that last around 60 minutes. Document the total time spent with the patient, ensuring that most of the session involves the patient's presence.
• Incomplete or unclear documentation: Keep thorough and accurate records, clearly distinguishing between the medical evaluation and management and psychotherapy components. Include the reason for the encounter, relevant history, physical examination findings, diagnosis or clinical impression, rationale for ordering diagnostic or ancillary services, and the plan for care.
• Outdated coding practices: Stay informed about annual CPT code updates and ensure your documentation practices match these changes to maintain accurate and compliant coding.

Regularly review your billing processes and seek advice from coding experts or professional organizations when needed to avoid these common pitfalls. Accurate coding and documentation not only ensure proper reimbursement but also protect your practice from potential audits or legal issues.

How to Improve your CPT Code 90838 Reimbursement

Increasing reimbursement rates for CPT code 90838 involves accurate documentation, efficient billing processes, and staying informed about industry changes. Here are some strategies to help boost your reimbursement:

• Thorough documentation: Clearly separate the medical evaluation and management from the psychotherapy components in your documentation. Include all relevant details, such as the reason for the encounter, pertinent history, physical examination findings, diagnosis or clinical impression, and treatment plan.
• Accurate coding: Ensure that your coding staff knows the latest coding guidelines and regulations specific to CPT code 90838. Regularly review your coding practices and consider using coding software or outsourcing to professional coding companies to improve accuracy and reduce errors.
• Verify insurance coverage: Before providing services, confirm the patient's insurance coverage to ensure eligibility and prevent denials or underpayments. Stay current with any changes in coverage by regularly tracking updates to patient policies.
• Streamline billing processes: Develop a standardized billing routine that includes collecting patient information, verifying insurance coverage, and submitting claims. Use electronic billing systems to automate tasks, reduce errors, and improve efficiency.
• Leverage technology: Implement practice management software, automated claim scrubbing tools, and electronic remittance advice (ERA) processing to enhance billing accuracy and efficiency. Use patient portals for online bill pay and communication to improve patient engagement and collection rates.
• Stay informed: Keep up with payer policies, industry changes, and annual CPT code updates by reviewing payer bulletins, attending conferences and workshops, and subscribing to relevant publications and newsletters. Establish relationships with payer representatives to stay informed about policy changes that may affect CPT code 90838 billing.

Regularly monitoring and analyzing your billing performance, investing in staff training and development, and reviewing and updating your contracts and fee schedules can also contribute to improving your CPT code 90838 reimbursement.

Frequently Asked Questions (FAQ)

What is the difference between CPT code 90838 and other psychotherapy codes?

CPT code 90838 stands out because it combines a 60-minute psychotherapy session with medical evaluation and management services. Other psychotherapy codes, such as 90834 (45 minutes) and 90837 (60 minutes), do not include the medical component.

Can I bill CPT code 90838 for a session that is shorter than 60 minutes?

No, CPT code 90838 is specifically meant for sessions lasting about 60 minutes. If your session is shorter, consider using a different code that better matches the duration of the service provided.

Is it necessary to document both the medical and psychotherapy components of the session?

Yes, to use CPT code 90838, you must clearly document both the medical evaluation and management and the psychotherapy components of the session. This documentation is important for justifying the use of the code and avoiding claim denials or audits.

Can I use CPT code 90838 for family therapy sessions?

CPT code 90838 can be used for sessions that involve the patient and/or family members, as long as the patient is present for most of the session. However, if you provide family therapy without the patient present, use CPT code 90846 instead.

What if I provide psychotherapy and medical evaluation and management services separately on the same day?

In this situation, bill the services separately using the appropriate codes (e.g., 90834 for a 45-minute psychotherapy session and 99213 for evaluation and management) instead of using CPT code 90838.

How can I ensure that I'm using CPT code 90838 correctly?

To correctly use CPT code 90838, make sure that your session includes a significant level of medical evaluation and management, a distinct psychotherapy component, and lasts about 60 minutes. Thorough documentation is key to supporting the use of this code and avoiding compliance issues.

CPT Code 90838 Bill Code Limitations

While CPT code 90838 is useful for billing psychotherapy with medical evaluation and management, it's important to be aware of its limitations and restrictions. Here are some key factors to consider:

• Time-based coding: CPT code 90838 applies specifically to sessions lasting about 60 minutes. Using this code for sessions that are significantly shorter or longer may lead to claim denials or audits.
• Documentation requirements: Thorough and accurate documentation is necessary when using CPT code 90838. Clearly separate the medical evaluation and management from the psychotherapy components, and include all relevant details to justify the use of this code.
• Frequency limitations: Stay informed about any frequency limits imposed by payers for CPT code 90838. Excessive use of this code or exceeding the allowed frequency might result in reduced reimbursement or claim denials.
• Unbundling and upcoding: Avoid billing separately for services that should be billed together under CPT code 90838 (unbundling) or billing for a more expensive service than actually provided (upcoding). These practices can lead to penalties and fines.
• Medical Unlikely Edits (MUEs): Medicare and other payers use MUEs to prevent payment for an inappropriate number or quantity of the same service on a single day. Be aware of these edits when billing CPT code 90838 to avoid overbilling.
• Variability in reimbursement: Reimbursement rates for CPT code 90838 can vary across different organizations and payers, which may sometimes cause delays or discrepancies in payment.

Keeping up with annual CPT code updates, payer policies, and industry changes is important to ensure compliance and avoid potential issues when using CPT code 90838. Regularly review your billing processes, invest in staff training, and consult with coding experts or professional organizations to improve your use of this code and maintain accurate, compliant billing practices.

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