CPT Code 90853: When and How to Maximize Reimbursement for Therapists

Navigating medical billing can feel daunting but a key part of securing proper reimbursement involves knowing and correctly using CPT codes. In this article, we'll focus on CPT code 90853, which mental health professionals find particularly relevant.

By learning to use CPT code 90853 effectively, you can improve your billing practices and increase reimbursement. This guide offers the knowledge and tools you need to confidently apply this code in your practice. 

This article covers a detailed guide on CPT code 90853, including its definition, usage, billing criteria, and common pitfalls. It helps healthcare professionals learn how to use and increase reimbursement for this specific CPT code. 

What is CPT Code 90853?

CPT code 90853 is a Current Procedural Terminology (CPT) code for billing group psychotherapy sessions. This code is meant for group therapy sessions conducted by a physician or a licensed mental health  professional.

When to use CPT Code 90853

CPT code 90853 applies to various situations involving group psychotherapy sessions. Here are some key guidelines for using this code:

• Group therapy sessions: Use CPT code 90853 when billing for group psychotherapy sessions led by a physician or a licensed mental health  professional. These sessions typically involve multiple patients, who are not family members, working on similar issues or goals. 
• Interactive group psychotherapy: This code suits interactive group psychotherapy, where participants engage in discussion, share experiences, and provide support to one another under the guidance of a therapist.

It's important to note that CPT code 90853 should only be used when the group therapy session is a distinct service, separate from any other services provided on the same day. When medically indicated, the interactive complexity add-on code (+90785) may be billed in conjunction with this code. While there is no specific minimum time requirement for this code, group therapy sessions are typically 45-60 minutes in length.

When documenting the use of CPT code 90853, ensure that the medical necessity of the group therapy session is clearly established and that the session is directly related to the patient's treatment plan. Maintain detailed records of the session, including the date, duration, and a summary of the topics discussed or techniques used.

When not to use CPT Code 90853

While CPT code 90853 often applies to group psychotherapy sessions, there are situations where it shouldn't be used. Here are some common mistakes to avoid when working with this code:

• Individual therapy sessions: CPT code 90853 is meant specifically for group psychotherapy. It should not apply to individual therapy sessions, even if similar issues are addressed. For one-on-one therapy, use the appropriate individual therapy CPT codes, such as 90832, 90834, or 90837, based on the session length.
• Multiple-family group psychotherapy: CPT Code 90853 is not intended for multiple-family group therapy, which involves multiple families working together to address shared concerns and support each other. Instead use the specific multiple-family group psychotherapy code 90849.
• Non-psychotherapy group sessions: Not every group session qualifies for CPT code 90853. Educational classes, support groups, or skill-building workshops that don't involve psychotherapy should not be billed with this code. These sessions might require different CPT codes or might not be billable at all, depending on the payer's guidelines.
• Ancillary services: CPT code 90853 shouldn't apply to ancillary services, like group art therapy, music therapy, or other adjunctive therapies, unless they're an essential part of the group psychotherapy session. These services might have their own specific CPT codes or be considered part of the group psychotherapy service.
• Medication management: If the main purpose of the group session is medication management, don't use CPT code 90853. Instead, opt for the appropriate evaluation and management (E/M) codes or medication management codes, such as 90863 or 90838, depending on the services provided.

Requirements and Billing Criteria for CPT Code 90853

To ensure proper reimbursement and compliance when billing with CPT code 90853, therapists need to meet specific documentation and billing criteria. Here are the key requirements:

• Group therapy setting: The service takes place in a group therapy setting, with multiple patients participating in the session. The group should focus on a common therapeutic goal or issue.
• Qualified healthcare professional: A physician or another qualified healthcare professional, such as a licensed clinical psychologist or clinical social worker, leads the group therapy session.
• Medical necessity: The group therapy session must be medically necessary and directly related to the patients' treatment plans. Documentation should clearly establish the need for group therapy and its relevance to the participants' mental health concerns.
• Documentation: Keep detailed records of each group therapy session, including the date, duration, participants, and a summary of the topics discussed or techniques used. The documentation should support the medical necessity of the service and show the active participation of the healthcare professional leading the session.
• Distinct service: Use CPT code 90853 only when the group therapy session is a distinct service, separate from any other services provided on the same day. If other services are provided, they should be billed separately using the appropriate CPT codes.
• Payer guidelines: Be familiar with the specific billing guidelines and requirements of each payer, as they may have additional criteria or limitations for reimbursement under CPT code 90853.

Regularly review and update your documentation practices to ensure they meet the latest billing and compliance standards. Seek guidance from professional organizations, billing experts, or legal counsel if you have questions or concerns about using CPT code 90853 in your practice.

Common Pitfalls to Avoid for CPT Code 90853

When billing with CPT code 90853, therapists might face some common issues that can cause claim denials or reduced reimbursement. Here are a few frequent mistakes and misunderstandings to be aware of:

• Misusing the code for individual therapy: CPT code 90853 is specifically for group psychotherapy sessions. Using this code for individual therapy sessions will likely result in claim rejections, as it does not accurately reflect the service provided.
• Inadequate documentation: Failing to keep thorough, accurate records of group therapy sessions can hinder reimbursement. Make sure your documentation clearly shows the medical necessity of the session, its connection to the participants' treatment plans, and the active involvement of the qualified healthcare professional leading the session.
• Neglecting payer-specific guidelines: Each payer may have unique requirements or limitations for reimbursement under CPT code 90853. Familiarize yourself with these guidelines to avoid claim denials or delays in payment.
• Unbundling services: When billing for group therapy sessions, avoid unbundling services by billing separately for components that should be included under CPT code 90853. This practice can raise concerns with payers and potentially lead to audits or other consequences.
• Upcoding or downcoding: Using a higher-level code than necessary for the group therapy session (upcoding) or using a lower-level code than appropriate (downcoding) can both cause issues. Upcoding can trigger audits and legal problems, while downcoding can result in lost revenue and inaccurate representations of the level of care provided.

To avoid these pitfalls, focus on ongoing education and training for you and your staff on proper CPT code usage, stay informed on payer requirements, and maintain meticulous documentation practices. Regularly review your billing processes and seek guidance from experts when needed to ensure compliance and optimal reimbursement.

How to Improve Your CPT Code 90853 Reimbursement

To improve reimbursement for CPT code 90853, try these strategies:

• Accurate documentation: Keep detailed, accurate records of group therapy sessions, clearly showing medical necessity and the therapist's active role. Use standardized templates and EHR systems to maintain consistency and completeness.
• Proper coding: Stay updated on billing codes, reimbursement rates, and payer policies. Ensure clinical staff understand the importance of accurate charge documentation and communicate billable services effectively to the billing team.
• Technology and automation: Use practice management software, automated claim scrubbing tools, and electronic remittance advice (ERA) processing to enhance billing efficiency and accuracy. Automate eligibility verification and coverage tracking to reduce errors and prevent complications.
• Payer relationships: Develop relationships with payer representatives to keep informed about policy updates and navigate changes. Regularly review payer bulletins, attend industry events, and subscribe to relevant publications to stay current on reimbursement trends.
• Staff training: Focus on ongoing education and professional development for staff on billing best practices, coding updates, and documentation requirements. Promote a culture of continuous learning and improvement to optimize reimbursement.
• Charge capture audits: Conduct regular audits to find missed charges and ensure all billable services are accurately captured. Train clinical staff on the importance of comprehensive charge documentation.
• Appeals process: Understand and navigate the appeals process for denied claims or underpayments related to CPT code 90853. Persistence and thorough documentation can help secure fair compensation for services provided.

Frequently Asked Questions (FAQ)

What is the difference between CPT code 90853 and other group therapy codes?

CPT code 90853 applies specifically to group psychotherapy sessions led by a physician or other licensed mental health professional. Other group therapy codes, such as 90849 for multiple-family group psychotherapy have different requirements and are used in particular situations.

Can I bill CPT code 90853 for individual therapy sessions?

No, CPT code 90853 is designated only for group psychotherapy sessions. Individual therapy sessions should use the appropriate individual therapy CPT codes, like 90832, 90834, or 90837, depending on the session length and type of service provided.

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Can I bill CPT code 90853 for non-psychotherapy group sessions?

No, CPT code 90853 is intended specifically for group psychotherapy sessions. Educational classes, support groups, or skill-building workshops that do not involve psychotherapy should not use this code. These sessions may need different CPT codes or might not be billable, depending on the payer's guidelines.

What documentation is required when billing CPT code 90853?

When billing with CPT code 90853, maintain detailed records of each group therapy session, including:

• Date and duration of the session
• List of participants
• Summary of topics discussed or techniques used
• Explanation of medical necessity and relevance to participants' treatment plans
• Proof of active participation by the healthcare professional leading the session

Are there any payer-specific guidelines for billing CPT code 90853?

Yes, each payer may have specific requirements or limitations for reimbursement under CPT code 90853. Familiarize yourself with these guidelines to prevent claim denials or payment delays. Regularly review payer bulletins, attend industry events, and subscribe to relevant publications to stay informed on reimbursement trends and requirements.

CPT Code 90853 Bill Code Limitations

While healthcare providers frequently use CPT code 90853 for billing group psychotherapy sessions, understanding its limitations and restrictions is necessary for accurate coding and compliance. Here are some important points to consider:

• Distinct service: Use CPT code 90853 only when the group therapy session stands as its own service, separate from any other services provided on the same day. Bill other services separately with the appropriate CPT codes.
• Qualified healthcare professional: A physician or another qualified healthcare professional, such as a licensed clinical psychologist or clinical social worker, must lead the group therapy session. Sessions led by non-qualified professionals don't qualify for billing under CPT code 90853.
• Payer-specific guidelines: Each payer may have particular requirements or limitations for reimbursement under CPT code 90853. Familiarize yourself with these guidelines to avoid claim denials or payment delays.
• Documentation requirements: Keep detailed records of each group therapy session, including the date, duration, participants, and a summary of the topics discussed or techniques used. The documentation should support the medical necessity of the service and show the active participation of the healthcare professional leading the session.

Staying informed on the latest billing guidelines and requirements for CPT code 90853 is important. Regularly review payer bulletins, attend industry events, and seek guidance from professional organizations or billing experts to ensure compliance and achieve appropriate reimbursement for your group psychotherapy services.