Billing psychotherapy add-ons with E/M: a pre-submission checklist for PMHNPs

When a PMHNP manages medication and also provides psychotherapy in the same visit, the claim carries two codes: an E/M code for the medical visit and a psychotherapy add-on for the therapy. Payers look closely at that pair, and small gaps in coding or documentation are a common reason these claims are denied or paid wrong.

What the add-on codes are

The psychotherapy add-on codes are 90833, 90836 and 90838. An add-on code can’t stand on its own: it is reported together with a primary service, which here is an E/M code for the same visit by the same provider.

That pairing is what makes these claims different from a psychotherapy-only visit, which uses the stand-alone codes instead.

Picking the right code by time

The add-on is chosen by the time spent on psychotherapy only. Under the CPT time rule, each code covers a range of minutes:

Less than 16 minutes of psychotherapy isn’t reportable as an add-on. If the note doesn’t state the psychotherapy time, the code can’t be supported, even when the visit clearly included therapy.

Keeping E/M and therapy separate

The E/M and the psychotherapy have to be significant and separately identifiable services. In practice that means the note should let a reviewer see two pieces of work:

• the medical part: assessment, medication management and the decision-making behind it;
• the psychotherapy part: the approach used, what was addressed, and how long it took.

Time spent on psychotherapy can’t also be counted toward the E/M. Many practices select the E/M level by medical decision-making when an add-on is billed, so the two never overlap.

When not to bill an add-on

The add-ons belong with an E/M visit. They aren’t reported with the psychiatric diagnostic evaluations, 90791 or 90792, on the same day. If an evaluation and a medication visit fall on the same date, it is worth checking the claim before it goes out rather than after it comes back.

For telehealth visits, the codes themselves don’t change, but the place of service and modifier do, and these differ by payer and change often. I check each payer’s current rules on every telehealth claim.

Pre-submission checklist

This is the short list I run through before an E/M + add-on claim is submitted:

1. 01
   An E/M is on the claim for the same dateThe add-on never goes out alone.
2. 02
   Psychotherapy time is written in the noteAnd it matches the add-on chosen: 16–37, 38–52 or 53+ minutes.
3. 03
   Both services are documented separatelyMedical decision-making for the E/M, and the therapy content and approach for the add-on.
4. 04
   No 90791 or 90792 on the same dayEvaluation days need a different setup.
5. 05
   Telehealth details match the payerPlace of service and modifier checked against that payer’s current rules.
6. 06
   The provider’s enrollment is in placeNP enrollment and credentialing with the payer, so the claim isn’t denied before coding is even looked at.

Common questions

This article is general information about psychiatric billing, not coding or legal advice. Payer policies differ and change, so check current CPT guidance and each payer’s rules for your claims.