CPT 90836 - Individual Psychotherapy with Evaluation and Management Services (45 Minutes)

CPT 90836 is defined as:

Individual psychotherapy, insight-oriented, behaviour-modifying, behavior modifying and/or supportive, in conjunction with an evaluation and management service; 45 minutes

This code is classified as an add-on psychotherapy code, meaning it cannot be billed independently of other services. It must always be reported in addition to a primary E/M service performed on the same date by the same provider.

The purpose of CPT 90836 is to capture encounters in which psychotherapy is medically necessary and clinically distinct from the E/M service. Many psychiatric patients require more than medication adjustments alone; they benefit from structured psychotherapy to improve coping skills, insight, emotional regulation, and overall functioning.

CPT 90836 supports care by enabling clinicians to:

• Deliver structured psychotherapy alongside medical decision-making
• Address emotional, cognitive, and behavioral contributors to mental illness
• Improve symptom control and functional outcomes
• Support treatment adherence and relapse prevention
• Manage complex or treatment-resistant psychiatric conditions
• Provide comprehensive care within a single visit

• A patient with major depressive disorder requiring medication adjustment and cognitive-behavioral therapy
• A patient with PTSD receiving trauma-focused therapy while medications are reviewed
• A patient with bipolar disorder undergoing mood stabilization and supportive psychotherapy
• A patient with anxiety disorder receiving pharmacologic management and skills-based therapy

CPT 90836 may be billed only by healthcare professionals who are authorized to provide both psychotherapy and evaluation and management (E/M) services under state law and payer policy.

Providers who may bill CPT 90836 include:

• Psychiatrists (MD or DO)
• Psychiatric Nurse Practitioners (PMHNP)
• Psychiatric Physician Assistants
• Other licensed medical providers permitted by state scope-of-practice laws

Providers who cannot bill CPT 90836 include:

• Psychologists
• Licensed Clinical Social Workers (LCSWs)
• Licensed Professional Counselors (LPCs)
• Marriage and Family Therapists (LMFTs)

These non-medical mental health providers may bill standalone psychotherapy codes, but cannot bill CPT 90836 because they do not perform evaluation and management services.

Key scope-of-practice considerations:

• The provider must personally perform both the psychotherapy and E/M services
• Services must be within the provider’s legal and licensure authority
• Payer credentialing requirements must be met
• Supervision rules do not allow incident-to billing for CPT 90836

Proper provider eligibility is essential for compliant billing and to avoid claim denials or recoupments related to scope-of-practice violations.

CPT 90836 is a time-based psychotherapy add-on code that represents 45 minutes of individual psychotherapy provided in conjunction with an evaluation and management service. Only the time spent delivering psychotherapy may be counted toward this code.

Psychotherapy time requirements

• 38 to 52 minutes of psychotherapy
• Time must be face-to-face or via real-time audio-visual telehealth
• Psychotherapy time must be documented clearly in the medical record
• E/M time is excluded from psychotherapy time calculations

Time that may be counted toward psychotherapy includes:

• Therapeutic dialogue and emotional processing
• Cognitive-behavioral interventions
• Insight-oriented or supportive psychotherapy
• Behavioral modification strategies
• Trauma-focused therapeutic work
• Interpersonal and coping-skills development

Time that does not count toward psychotherapy includes:

• Medication prescribing or adjustments
• Monitoring or discussing medication side effects
• History-taking for evaluation and management
• Mental status examination
• Care coordination unrelated to psychotherapy
• Documentation time

Accurate time tracking and documentation are critical to support compliant use of CPT 90836. Psychotherapy time should be explicitly stated or recorded using start and stop times to reduce audit risk and support medical necessity.

Because CP 90836 is an add-on code, it must be billed alongside a primary E/M code that accurately reflects the complexity of the medical portion of the visit.

Common E/M Codes Used

• 99202–99205 (New outpatient visits)
• 99212–99215 (Established outpatient visits)
• 99221–99223 (Initial inpatient care)
• 99231–99233 (Subsequent inpatient care)

Modifier requirements:

• Modifier 25 must be appended to the E/M code
• Modifier 25 indicates a significant, separately identifiable E/M service
• Failure to apply modifier 25 commonly results in claim denial

Proper pairing of CPT 90836 with the correct E/M code and modifier is essential for compliant billing and accurate reimbursement.

A critical requirement for billing CPT 90836 is the clear separation of psychotherapy and E/M services.

Evaluation and Management Includes:

• Diagnostic assessment
• Review of psychiatric symptoms
• Medication initiation or adjustment
• Monitoring side effects
• Risk assessment (suicidality, homicidality)
• Review of labs or medical conditions
• Treatment planning

Psychotherapy Includes:

• Exploration of thoughts, emotions, and behaviors
• Therapeutic techniques (CBT, supportive, psychodynamic)
• Coping skills development
• Addressing trauma, stressors, or interpersonal conflicts
• Emotional processing and insight building

Documentation must reflect two distinct services, not a blended narrative.

Thorough documentation is essential to support CPT 90836 and to withstand audits.

E/M Documentation

• Chief complaint
• Interval history
• Mental status examination
• Medical decision making
• Medication details
• Risk assessment
• Treatment plan

Psychotherapy Documentation

• Total psychotherapy time (or start/stop times)
• Type of psychotherapy used
• Therapeutic focus
• Patient response and engagement
• Progress toward treatment goals

Example Documentation Language

Provided 45 minutes of individual psychotherapy utilizing cognitive-behavioral techniques to address anxiety and maladaptive thought patterns. Patient actively engaged and demonstrated improved insight.

Psychotherapy billed under CPT 90836 must meet medical necessity requirements and be an essential component of the patient’s psychiatric treatment. The psychotherapy provided must address a diagnosed mental health condition and be required to improve symptoms, restore functioning, or prevent clinical deterioration.

Indicators of Medical Necessity

• Diagnosed mental health disorder
• Functional impairment
• Persistent or severe symptoms
• Risk of deterioration without psychotherapy
• Need for therapeutic intervention beyond medication

Common Associated Diagnoses

• Major depressive disorder
• Generalized anxiety disorder and other anxiety disorders
• Post-traumatic stress disorder
• Bipolar disorder
• Schizophrenia and other psychotic disorders
• Substance use disorders
• Attention-deficit/hyperactivity disorder: When psychotherapy is indicated

Psychotherapy that is primarily supportive or conversational without a therapeutic purpose does not meet medical necessity standards for CPT 90836.

Reimbursement for CPT 90836 varies based on payer policies, geographic location, and clinical setting. Because the code represents the delivery of both psychotherapy and evaluation and management services, reimbursement is generally higher than for standalone psychotherapy codes.

Key reimbursement considerations include:

• CPT 90836 is typically reimbursed in addition to the E/M service
• Payment rates vary by Medicare, Medicaid, and commercial insurers
• Proper documentation directly impacts reimbursement outcomes
• Claims may be denied if modifier 25 is missing or improperly applied
• Payer-specific psychotherapy limits or frequency edits may apply

Factors that influence payment:

• Selected E/M code and level of medical decision making
• Accurate psychotherapy time documentation
• Demonstrated medical necessity
• Place of service, including telehealth versus in-person
• Provider credentialing and contract terms

Best practices to support reimbursement:

• Verify payer-specific CPT 90836 coverage policies
• Ensure accurate E/M code selection
• Apply modifier 25 correctly
• Monitor denial trends and payer feedback
• Conduct periodic documentation and coding audits

Understanding payer-specific rules and maintaining compliant documentation are critical to ensuring consistent reimbursement for CPT 90836 services.

Providers must ensure that billing reflects the services actually delivered and aligns with regulatory and payer requirements.

Ethical and compliance principles include:

• Billing only for medically necessary psychotherapy
• Accurately reporting psychotherapy time without upcoding
• Avoiding routine or automatic use of CPT 90836
• Ensuring psychotherapy is not merely supportive conversation
• Maintaining professional boundaries during therapy sessions

Legal and regulatory considerations:

• Adherence to state scope-of-practice laws
• Compliance with payer-specific billing policies
• Proper use of modifier 25 on E/M services
• Documentation that supports both services as distinct
• Awareness of federal and state audit and enforcement standards

Compliance best practices:

• Provide ongoing coding and documentation training
• Conduct internal audits and peer reviews
• Update policies based on payer guidance changes
• Correct errors promptly when identified
• Maintain transparency in billing practices

Failure to follow ethical and compliance standards can result in claim denials, recoupments, penalties, or professional disciplinary action.

CPT 90836 may be billed for telehealth services when permitted by payer policy and applicable federal and state regulations. Telehealth delivery must meet the same clinical, documentation, and time requirements as in-person services.

Telehealth requirements for CPT 90836 include:

• Real-time, interactive audio-visual communication
• Both psychotherapy and E/M services provided during the same encounter
• Psychotherapy time meeting CPT 90836 thresholds
• Services delivered by an eligible provider
• Clinical appropriateness for telehealth delivery

Telehealth billing considerations:

• Use the appropriate telehealth modifier as required by the payer
• Report the correct place of service code
• Document patient consent for telehealth services when required
• Ensure privacy and confidentiality standards are met
• Apply modifier 25 to the E/M code when billing with CPT 90836

Documentation best practices for telehealth visits:

• Indicate that services were provided via telehealth
• Document the modality used (audio-visual)
• Record psychotherapy time clearly
• Maintain separate E/M and psychotherapy documentation
• Note any limitations related to telehealth delivery

Failure to meet telehealth-specific requirements may result in claim denial, delayed reimbursement, or audit exposure.

For practices seeking to enhance patient communication in telehealth settings, explore our virtual medical assistant services.

Beyond clinical care, understanding how medical virtual assistants transform healthcare can help practices reduce administrative burden and focus more on patient outcomes.

CPT 90836 represents an essential code for modern psychiatric practice, allowing providers to reflect the full scope of care delivered during complex visits that include both medical management and psychotherapy. When used appropriately, it supports high-quality patient care, accurate reimbursement, and regulatory compliance.

Summit RCM specializes in medical coding services help psychiatric and behavioral health practices reduce denials, mitigate audit risk, and maximize reimbursement through precise coding and thorough documentation review.

Contact Summit RCM today to learn how our experienced medical coding professionals can support your practice with reliable, compliant revenue cycle management solutions.