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90834 CPT Code (2022) – Description, Guidelines & Reimbursement

CPT 90834 can be reported for Psychotherapy (45 minutes). Post payment medical reviews have resulted in high error rates in the past. Services have been denied because submitted medical records did not meet documentation requirements.

90834 CPT Code Description

CPT 90834 is described as: Psychotherapy, 45 minutes with patient. A psychotherapy session is usally between 38 to 52 minutes. The provider performs a series of techniques for treating the psychiatric disorders of the patient.

The 90834 CPT code a telemed code and part of the merit based incentive payment system.

90834 CPT Code Requirements

The following documentation if required for each date of service:

  • Documentation of measurable goals on the treatment plan;
  • Detailed summary of the psychotherapy sessions, including descriptive documentation of therapeutic interventions;
  • Degree of patient participation and interaction with the therapist;
  • Reaction of the patient to the therapy sessions;
  • Documented progress toward measurable goals since the last sessions; and changes or lack of changes in the patient’s symptoms or behavior;
  • Documentation of adjustments in the treatment plan that reveal the dynamics of treatment.

CPT 90834 Coding Guidelines

The documentation for the 90834 CPT code should include on a periodic basis the patient’s capacity to participate and benefit from psychotherapy.

Such periodic documentation should include the estimated duration of treatment in terms of number of sessions required and the target symptoms, measurable and objective goals of therapy related to changes in behavior, thought processes and/or medications, methods of monitoring outcome, and why the chosen therapy is an appropriate modality either in lieu of or in addition to another form of psychiatric treatment.

For an acute problem, there should be documentation that the treatment is expected to improve the mental health status or function of the patient.

For chronic problems, there must be documentation indicating that stabilization of mental health status or function is expected.

Documentation for CPT 90834 will reflect adjustments in the treatment plan that reveals the dynamics of treatment.

It is expected that the treatment plan for a patient receiving outpatient psychotherapy (i.e., measurable and objective treatment goals, descriptive documentation of therapeutic intervention, frequency of sessions, and estimated duration of treatment) will be updated on a periodic basis, generally at least every three months.

The medical record documentation for the 90834 CPT code maintained by the provider must indicate the medical necessity of each psychotherapy session and include the following:

  • The presence of a psychiatric illness and/or the demonstration of emotional or behavioral symptoms sufficient to alter baseline functioning; and
  • The degree of patient participation and interaction with the therapist, the reaction of the patient to the therapy session, documentation toward goal oriented outcomes and the changes or lack of changes in patient symptoms and/or behavior as a result of the therapy session; and
  • A detailed summary of the session, including descriptive documentation of therapeutic interventions such as examples of attempted behavior modification, supportive interaction, and discussion of reality; and
  • The rationale for any departure from the plan or extension of therapy should be documented in the medical record. The therapist must document patient/therapist interaction in addition to an assessment of the patient’s problem(s).

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