How To Use CPT Code 90838

CPT 90838 refers to a 60-minute psychotherapy session performed with an evaluation and management service. This article will cover the description, procedure, qualifying circumstances, usage, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 90838.

1. What is CPT 90838?

CPT 90838 is a code used to describe a 60-minute psychotherapy session performed in conjunction with an evaluation and management (E/M) service. This code is specifically used when the provider spends a minimum of 53 minutes up to 60 minutes face-to-face with the patient, in addition to the separate E/M service performed in the same session.

2. 90838 CPT code description

The official description of CPT code 90838 is: “Psychotherapy, 60 minutes with patient when performed with an evaluation and management service (List separately in addition to the code for primary procedure)”.

3. Procedure

The 90838 procedure involves the following steps:

1. Provider conducts an evaluation and management service for the patient.
2. Provider engages in a face-to-face psychotherapy session with the patient for a minimum of 53 minutes up to 60 minutes.
3. Provider uses various techniques to explore the patient’s thoughts, feelings, and behaviors, aiming to improve their mental health.
4. Provider documents the session and the E/M service separately.
5. Provider bills CPT 90838 in addition to the primary E/M service code.

4. Qualifying circumstances

Patients eligible to receive CPT code 90838 services are those who require both an evaluation and management service and a psychotherapy session in the same visit. These patients typically have mental or emotional health problems that need to be addressed through talk therapy in conjunction with an E/M service. The provider must spend a minimum of 53 minutes up to 60 minutes in the psychotherapy session to qualify for billing CPT 90838.

5. When to use CPT code 90838

It is appropriate to bill the 90838 CPT code when the following conditions are met:

• The provider performs an evaluation and management service during the same session as the psychotherapy.
• The psychotherapy session lasts for a minimum of 53 minutes up to 60 minutes.
• The provider documents the E/M service and the psychotherapy session separately.

6. Documentation requirements

To support a claim for CPT 90838, the following information needs to be documented:

• Date and duration of the psychotherapy session.
• Specific techniques used during the psychotherapy session.
• Details of the patient’s thoughts, feelings, and behaviors explored during the session.
• Progress made or goals achieved during the session.
• Separate documentation of the evaluation and management service performed in the same session.

7. Billing guidelines

When billing for CPT code 90838, keep in mind the following guidelines:

• Bill CPT 90838 separately in addition to the primary E/M service code.
• Ensure that the psychotherapy session lasts for a minimum of 53 minutes up to 60 minutes.
• Document the E/M service and the psychotherapy session separately.
• Do not use CPT 90838 if the psychotherapy session is performed without an additional E/M service in the same session. In this case, use CPT 90837 instead.

8. Historical information

CPT 90838 was added to the Current Procedural Terminology system on January 1, 2013. The code was changed on January 1, 2017, with the previous descriptor being “Psychotherapy, 60 minutes with patient and/or family member when performed with an evaluation and management service (List separately in addition to the code for primary procedure)”.

9. Similar codes to CPT 90838

Five similar codes to CPT 90838 and how they differentiate are:

1. CPT 90832: A shorter psychotherapy session, lasting 30 minutes.
2. CPT 90833: A 30-minute psychotherapy session performed with an E/M service.
3. CPT 90834: A 45-minute psychotherapy session without an additional E/M service.
4. CPT 90836: A 45-minute psychotherapy session performed with an E/M service.
5. CPT 90837: A 60-minute psychotherapy session without an additional E/M service.

10. Examples

Here are 10 detailed examples of CPT code 90838 procedures:

1. A patient with depression receives a 60-minute psychotherapy session in addition to an E/M service to evaluate their medication management.
2. A patient with anxiety undergoes a 55-minute psychotherapy session along with an E/M service to assess their overall mental health.
3. A patient with post-traumatic stress disorder (PTSD) participates in a 58-minute psychotherapy session, followed by an E/M service to evaluate their progress.
4. A patient with bipolar disorder receives a 60-minute psychotherapy session in conjunction with an E/M service to monitor their medication effectiveness.
5. A patient with an eating disorder undergoes a 53-minute psychotherapy session along with an E/M service to assess their nutritional status and mental health.
6. A patient with obsessive-compulsive disorder (OCD) participates in a 57-minute psychotherapy session, followed by an E/M service to evaluate their response to treatment.
7. A patient with a personality disorder receives a 60-minute psychotherapy session in addition to an E/M service to assess their interpersonal relationships and coping strategies.
8. A patient with a substance use disorder undergoes a 56-minute psychotherapy session along with an E/M service to evaluate their recovery progress and medication management.
9. A patient with a history of self-harm participates in a 59-minute psychotherapy session, followed by an E/M service to assess their safety and mental health.
10. A patient with schizophrenia receives a 60-minute psychotherapy session in conjunction with an E/M service to monitor their medication adherence and symptom management.