Mental Health Billing Guide: CPT Codes for Therapy & Psychiatry
Billing for mental health services is often more nuanced and complex than other medical specialties. With multiple session types, varying lengths, and the integration of therapy and medical management, it’s easy for providers and billing teams to make costly mistakes. Yet, getting paid accurately and on time depends heavily on precise CPT code usage. This guide breaks down the essential CPT codes for therapy and psychiatry, explains documentation requirements, and highlights tools like MaxRemind that simplify behavioral health billing.
Understanding Mental Health CPT Codes
CPT codes (Current Procedural Terminology) are the universal language used to describe medical services for billing purposes. In mental health, these codes differentiate between therapy sessions, psychiatric evaluations, and medication management. Therapy codes generally reflect time-based services focused on behavioral techniques or talk therapy, while psychiatry codes often include evaluations, diagnoses, and pharmacological treatment.
Proper documentation is critical to justify the chosen code. This includes session duration, therapeutic interventions used, medical necessity, and, when applicable, prescription decisions. Missing or vague documentation can lead to denied claims or reimbursement delays.
CPT Codes for Therapy Services
Therapy codes are typically time-based and specific to the type of interaction. Some of the most commonly used psychotherapy CPT codes include:
| CPT Codes | Description |
|---|---|
| 90832 | Psychotherapy for 30 minutes with the patient |
| 90834 | Psychotherapy for 45 minutes |
| 90837 | Psychotherapy for 60 minutes |
Each of these codes requires documentation of session duration, focus, and progress. For sessions that include both psychotherapy and medication management, providers may use add-on codes:
+90833 / +90836 – These are used in combination with E/M codes to represent psychotherapy alongside evaluation and management services.
| Family Therapy CPT Codes | |
|---|---|
| CPT Codes | Description |
| 90846 | Family or couples psychotherapy without the patient present |
| 90847 | Family or couples psychotherapy with the patient present |
To avoid denials, documentation must reflect who was present, the reason for the session, and the therapeutic focus.
CPT Codes for Psychiatry Services
Psychiatry codes are primarily used for diagnostic evaluations and medication management. Two of the most important codes for psychiatric intake are:
| Codes | Description |
|---|---|
| 90791 | Psychiatric diagnostic evaluation without medical services |
| 90792 | Psychiatric diagnostic evaluation with medical services(typically used by psychiatrists or advanced nurse practitioners |
For ongoing sessions that involve prescribing or managing medications, E/M (Evaluation and Management) codes come into play. Codes like 99202–99215 are selected based on the complexity of the visit and whether it was a new or established patient. These codes can be combined with psychotherapy codes when both therapy and medical services are provided in the same session.
Common combinations include 90833 + 99214, where the session involves both medication management and psychotherapy. The documentation must reflect two distinct components: mental health treatment and clinical decision-making around medication.
Coding for Telehealth Therapy
As telehealth continues to grow in mental health, billing for virtual sessions requires adherence to specific coding rules. The Modifier 95 is typically used to indicate a telehealth service, along with the appropriate Place of Service (POS) code. Most common are:
| Coding for Telehealth Therapy | |
|---|---|
| Codes | Description |
| POS 10 | Telehealth is provided in the patient’s home |
| POS 02 | Telehealth not provided in the patient’s home |
It’s also important to understand payer-specific telehealth policies. Some insurers require pre-authorization or restrict certain CPT codes for virtual care. Documentation should clearly state the modality (audio-video or audio-only), session length, and patient consent for telehealth.
Common Billing Mistakes to Avoid
Mental health billing errors are common and often avoidable. Some of the most frequent issues include:
- Using the wrong CPT code based on session length
- Failing to include the E/M component when medication is managed
- Not appending Modifier 95 for telehealth services
- Overlooking payer-specific coverage guidelines
- Insufficient documentation, especially for telehealth or dual services (e.g., therapy + med management)
Training staff and using smart billing systems can drastically reduce these errors.
How AI and MaxRemind Improve Mental Health Billing
Technology now plays a significant role in preventing billing mistakes. MaxRemind, for example, leverages AI to assist with real-time coding and compliance. Its intelligent system reviews clinical notes, suggests appropriate CPT codes, and prompts providers to complete necessary documentation before claim submission.
Key features of MaxRemind’s mental health billing solutions include:
- AI-assisted CPT code recommendations
- Built-in documentation reminders to ensure medical necessity is met
- Real-time claim scrubbing that flags errors before submission
- Payer-specific rules integrated directly into the platform
- Automated denial management and HIPAA-compliant workflows
These tools not only reduce administrative burden but also ensure faster reimbursements and lower denial rates.
Best Practices for Clean Mental Health Claims
Maintaining a healthy revenue cycle in behavioral health begins with proactive processes. To ensure claims are paid accurately and promptly, mental health providers should:
- Verify insurance coverage and benefits before each session
- Train clinicians on documentation requirements and coding basics
- Use billing software that supports CPT auto-coding and compliance checks
- Consider outsourcing to billing partners who specialize in mental health services
By standardizing workflows and leveraging technology, practices can eliminate guesswork and focus more on patient care.
Conclusion
Accurate CPT coding is not just an administrative task—it’s a core part of sustaining a successful mental health practice. Whether you offer therapy, psychiatry, or both, correct billing ensures your services are reimbursed fairly and on time. With increasing demand for mental health services and the growing role of telehealth, billing efficiently is more important than ever.
If you’re looking to streamline your mental health billing processes, MaxRemind offers purpose-built tools that combine AI, automation, and compliance. Schedule a free demo today and see how much simpler your therapy and psychiatry billing can be.
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FAQs
- What CPT codes are used for therapy sessions?
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Common therapy CPT codes include 90832 (30 mins), 90834 (45 mins), and 90837 (60 mins) for individual psychotherapy.
- What is the difference between 90791 and 90792?
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90791 is a psychiatric evaluation without medical services, while 90792 includes medical services like prescribing or managing medications.
- Can you bill therapy and medication management together?
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Yes, using combination codes like 90833 or 90836 with appropriate E/M services, assuming the documentation supports it.
- How do I bill telehealth therapy sessions?
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Use Modifier 95 with appropriate CPT codes and indicate the telehealth location (POS 10 or 02) as per payer guidelines.
- What’s the most common billing mistake in mental health practices?
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The most common mistakes include using the wrong session-length code, missing modifiers, and failing to check prior auth requirements.
