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90838 CPT Code: Expert Guide to Maximize Your Reimbursement

Michael Reider

Mar 28, 2025

Mental health professionals should pay attention to the projected Medicare reimbursement rate of $122.92 for 90838 in 2025. This billing code plays a vital role in their practice. Getting maximum reimbursement depends on your understanding and proper implementation.

CPT code 90838 applies to 60-minute psychotherapy sessions that can last between 53 and 67 minutes. Your reimbursement rates as a mental health provider can change by a lot based on where you practice. Insurance provider policies and case complexity also affect the rates. This applies to psychiatrists, psychologists, clinical social workers, and licensed professional counselors. You need proper documentation to get your claims approved. Your records must include session times, diagnosis, therapeutic interventions, and treatment progress.

This detailed guide will help you through the complexities of 90838 CPT code billing. You'll learn ways to stay compliant and make the most of your practice's revenue potential.

The Financial Impact of CPT 90838 on Your Practice

CPT code 90838 can make a big difference in your practice's revenue stream. You need to think carefully about using this code versus other psychotherapy codes to balance potential income and session costs.

Revenue potential of 90838 vs. other psychotherapy codes

Medicare reimbursement rates show the real value of CPT code 90838. Medicare pays $118.53 for 90838 in 2024, and this will likely go up to $122.92 in 2025 [1]. These rates are much higher than those for shorter sessions.

Here's what you need to know about different psychotherapy codes:

90832: Used for 30-minute sessions (16-37 minutes)
90834: Used for 45-minute sessions (38-52 minutes)
90837: Standalone 60-minute sessions (53+ minutes)
90838: Add-on code for 60-minute sessions with Evaluation and Management services

The main difference between 90837 and 90838 is how they work. Both codes cover similar time periods, but 90838 must go with an E/M service code. This combination can lead to higher total reimbursement when both services are needed and well-documented.

Payment rates change based on several factors. Your location matters a lot - urban providers often get different rates than rural ones. Insurance companies' policies, your credentials, and how complex the cases are also affect your payments. It's best to check with each insurance company directly to know the current rates for your practice.

Crisis situations can bring in even more revenue with codes 90839 (first 60 minutes) and 90840 (each additional 30 minutes). Medicare pays 150% of the standard fee schedule amount for these services in non-facility settings [3]. This higher rate reflects how intense and urgent crisis care can be.

Cost-benefit analysis of longer sessions

Longer sessions might bring in more money per appointment, but research paints a complex picture. A five-year study comparing short-term and long-term therapies found something interesting. While longer therapies worked slightly better eventually, they cost much more, making them less economical than shorter approaches [4].

Session frequency affects financial results too. A study of twice-weekly versus once-weekly sessions showed the twice-weekly group had higher societal costs (mean difference €2065) without matching clinical benefits [5]. The incremental cost-effectiveness ratio (ICER) was -1670. This means getting one point better on the Beck Depression Inventory-II scale in the twice-weekly group needed an extra €1670 per person [5].

Group therapy might be your best bet for both results and cost-effectiveness. Research shows it works better than individual therapy (by 0.34, 0.46, and 0.26 standard deviations across different analytical models) [6]. This means group sessions with proper coding could help you optimize both clinical outcomes and revenue.

Here's how to manage your finances better:

Use 90838 only for complex cases that need both psychotherapy and medical evaluation
Keep detailed records to show why longer sessions are needed
Check insurance policies about 90838 frequency and authorization requirements
Look at your per-minute reimbursement across different codes to find what works best with your payers

90838 can bring in more money than shorter session codes, but you need to balance this against patient needs, payer rules, and the cost of longer appointments. The smart move is to use this code when it makes clinical sense, not as your go-to billing option. This approach helps you improve both patient care and practice sustainability.

Proper Pairing of E/M Services with 90838 CPT Code

Medical providers need precision and attention to detail to pair Evaluation and Management (E/M) services with CPT code 90838. This add-on code must accompany an appropriate E/M service code. The combination works well for mental health providers who deliver both medical and psychotherapeutic care in one visit.

Selecting the appropriate E/M code level

The pairing of E/M service with psychotherapy requires you to select the E/M code based exclusively on medical decision making (MDM), not time. This makes a big difference from standalone E/M services [7]. You can pair 90838 with these E/M codes:

Office or outpatient visits (99202-99215)
Hospital inpatient services (99221-99233)
Nursing facility services (99304-99316)
Home services (99341-99350)

Your MDM level depends on these components:

Number and complexity of problems addressed
Amount and complexity of data reviewed
Risk of complications or morbidity/mortality

You must meet or exceed two of these three elements to qualify for a specific level of decision-making [8]. To name just one example, managing multiple chronic illnesses that need medication adjustments usually needs a higher-level E/M code than treating a single stable condition.

Documentation to support both services

Your documentation should prove that both E/M and psychotherapy were significant and separate services [9]. Yes, it is the most basic requirement for proper pairing.

Your notes should have separate sections for each service type:

E/M documentation must include:

Medically appropriate history and examination
Clear documentation of medical decision making
Evaluation findings and treatment plan

Psychotherapy documentation must include:

Start and stop times or total time devoted to psychotherapy
Type and content of psychotherapy provided
Therapeutic techniques used
Patient progress and response to treatment [8]

The time you spend on psychotherapy activities cannot overlap with E/M activities [7]. Time spent reviewing medications counts as E/M service, while discussing emotional responses to life events belongs to psychotherapy service.

Common pairing mistakes to avoid

Never use standalone psychotherapy codes (90832, 90834, 90837) with E/M services on the same day [8]. You should use the appropriate add-on codes (90833, 90836, 90838).

Medical decision making should be your only criterion for E/M code selection when pairing with psychotherapy add-on codes [7].

You cannot report prolonged service codes with psychotherapy add-on codes [10]. This common billing error leads to claim denials.

Some providers add E/M codes to psychotherapy services without proper documentation support [7]. This practice puts you at risk for audit findings and potential recoupment.

Denied claims often result from not documenting medical necessity for both services. Each component needs its own medical necessity proof [7].

These pairing principles help you get appropriate reimbursement for CPT code 90838 while keeping your billing practices compliant.

Insurance Verification and Prior Authorization Strategies

Insurance management is the life-blood of getting maximum reimbursement for CPT code 90838. Your precisely coded sessions might face denials without proper verification and authorization processes.

Pre-session insurance eligibility checks

You should verify patient insurance details before every therapy session, especially when you have third-party insurance covering mental health services [11]. This verification helps you prevent unexpected claim denials and surprise bills for patients.

Monthly verification practices make sense for ongoing clients. As one billing expert notes, "You don't want your clients to end up with a big bill" [12]. Insurance coverage changes can happen without warning, which makes regular verification vital for practices using 90838 CPT code.

Common verification methods include:

Calling the number on the back of the patient's insurance card
Logging into the provider portal for payers you're credentialed with
Using specialized verification services or software

Insurance companies often set specific policies about how often you can use 60-minute sessions with 90838 code. They might ask for extra justification to use these instead of shorter session codes.

Getting authorizations for extended sessions

Authorization requirements for extended psychotherapy sessions vary by a lot between insurance carriers. Many insurers have unique preauthorization requirements just for code 90838 [13].

Your healthcare provider must submit an authorization request that shows the patient's condition, treatment plan using 90838, and clinical reasons for extended sessions [14]. Each insurer handles this differently, and you'll need patience to navigate the process.

Authorization usually takes days to weeks, so plan early to avoid delays in treatment [14]. Denied requests might need more information or an appeal - success isn't guaranteed but it's worth trying for the right cases.

Communicating with patients about coverage

Clear communication with patients about coverage matters most with 90838 CPT code sessions. You should discuss potential costs before starting extended sessions.

Progress notes should really document why extended therapy sessions make sense, particularly for trauma treatments and complex cases [15]. This documentation supports your reimbursement claims and helps explain to patients why longer sessions matter medically.

If you get a denial, talk through options with your patient. You can explore:

Different session frequency or duration
Self-pay options with clear fee structures
Appeals processes they can join

Open communication about insurance coverage builds trust with patients and protects your practice's financial health.

Overcoming Common 90838 CPT Code Denial Reasons

CPT code 90838 claims get denied more often than other psychotherapy codes, even with careful coding practices. A 2024 survey revealed more than 15% of legitimate claims from private payers face initial denials. About half of these denials get overturned through appeals. You need to know why these denials happen to get paid properly.

Medical necessity challenges

Insurance companies now use algorithms to check medical necessity. This often leads to wrong denials for valid 90838 services. Medicare has clear guidelines - "improvement" means comparing ongoing treatment with stopping it. Medical necessity exists if stopping services would make the patient worse or need hospitalization.

Keeping patients at their current functional levels counts as improvement for chronic conditions. This prevents them from getting worse. Your notes must show why longer sessions help complex needs that shorter ones can't handle.

Frequency limitations

Each insurer sets different limits on how often you can use 90838. Using this code too much can trigger automatic denials or reviews, even when you have good reasons.

Here's how to handle these limits:

Check each payer's specific frequency rules
Keep track of how often you use it per patient
Save 90838 for cases that clearly need it
Switch to other codes when it makes sense

Documentation insufficiencies

Poor documentation tops the list of reasons for 90838 denials. Your records must show clear differences between E/M and psychotherapy services. You need to write down exact start and stop times, therapy techniques you used, and solid reasons for longer sessions.

Patient records should match the psychiatric diagnostic procedures description. They must show time spent in therapy and the specific methods you used to help create change.

Successful appeal strategies

You can win about half of initial denials, so good appeal strategies matter. Ask for written denial reasons first. Get copies of any plan rules they used to deny the claim.

Write appeals that tell the patient's full treatment story. Show why they need the denied service. Give real examples of what could go wrong if care stops. Keep your tone professional but firm.

Quick action matters - payers have strict deadlines for appeals. Start your appeal right after getting the denial. Make sure your supporting documents are well-organized and match the denial reason.

Telehealth Considerations for 90838 Reimbursement

Telehealth has made mental health services more accessible to patients. Healthcare providers need to understand specific billing requirements for CPT code 90838 in virtual settings. Your remote psychotherapy sessions will receive maximum reimbursement when you understand platform requirements, state regulations, and modifier usage.

Platform requirements for compliant sessions

Medicare specifies that telehealth platforms must support two-way, interactive, audio-video technology for proper 90838 reimbursement [16]. Patients can use audio-only technology through December 31, 2024. This accommodation helps patients who face technical limitations or have different priorities [16].

Your telehealth platform must be HIPAA-compliant to qualify for reimbursement. Non-compliant platforms put your practice and reimbursement at risk, making this requirement non-negotiable.

Documentation for telehealth sessions using 90838 must include:

Session start and end times
Confirmation that the session was conducted via telehealth
Patient's location during the session
Provider's location during the session
Type of technology used (video or audio-only)

State-specific telehealth regulations

Each state has different reimbursement policies that affect 90838 telehealth service billing. Some states have telehealth parity laws that make insurers reimburse virtual services at rates similar to in-person care [17].

Licensure requirements create another regulatory challenge. The COVID-19 pandemic allowed licensed mental health providers to work across state lines temporarily. This change helped patients in rural areas get better access to care [18]. Many temporary waivers have expired, so check your current regulations.

Medicare lists specific approved telehealth sites. These include the patient's home for substance use disorder treatment or co-occurring mental health disorders [16]. Other locations that qualify are physician offices, hospitals, rural health clinics, and community mental health centers [19].

Using appropriate telehealth modifiers

The right modifier selection plays a vital role in successful 90838 telehealth claims. Common modifiers include:

Modifier 95: Shows synchronous telehealth service via immediate interactive audio and visual communications [17]
Modifier GT: Used for interactive audio and video telecommunications systems [18]
Modifier GQ: Applied for asynchronous telehealth systems like store-and-forward telemedicine [18]
Modifier 93: Specifies synchronous audio-only communication [17]

Medicare stopped requiring the GT modifier in 2017. They now use Place of Service code 02 for telehealth services [19]. Some states have kept specific requirements. North Carolina still needs the GT modifier for audio-visual sessions [20].

Check requirements with each payer to get proper 90838 telehealth reimbursement in 2025. Policies keep changing faster among insurance providers and state regulations.

Conclusion

Your success with CPT code 90838 billing depends on how well you manage several aspects of your practice. The 2025 Medicare reimbursement rate of $122.92 makes this code attractive financially. However, you need precise documentation, proper E/M code pairing, and a full picture of insurance coverage to maximize your returns.

Note that you should only use extended sessions when they serve clear clinical purposes, not as default billing options. Your records must clearly separate E/M services from psychotherapy components and show medical necessity for both. You can reduce denial risks by a lot when you regularly check insurance eligibility and manage authorizations properly.

There's another reason things get complex with telehealth - platform requirements, state regulations, and modifier usage. You need to keep up with changing telehealth policies, especially as temporary pandemic-era allowances end. By doing this and following these guidelines, you'll boost your practice's revenue potential while you retain control and deliver quality patient care.

FAQs

What is the reimbursement rate for CPT code 90838 in 2025?

The projected Medicare reimbursement rate for CPT code 90838 in 2025 is $122.92. However, actual reimbursement can vary based on factors such as geographic location, insurance provider policies, and case complexity.

How does CPT code 90838 differ from other psychotherapy codes?

CPT code 90838 is specifically for 60-minute psychotherapy sessions (53-67 minutes) and must be paired with an Evaluation and Management (E/M) service code. It's an add-on code, unlike standalone codes like 90837, and can potentially result in higher combined reimbursement when both services are medically necessary.

Can I bill both an E/M code and 90838 for the same session?

Yes, you can bill both an E/M code (such as 99214) and 90838 for the same session. However, the psychotherapy service must be performed in addition to the E/M service, and the time for each must be separately documented. The E/M code should be reported first, followed by 90838.

What documentation is required for 90838 telehealth sessions?

For telehealth sessions using 90838, documentation should include session start and end times, confirmation that the session was conducted via telehealth, patient and provider locations during the session, and the type of technology used (video or audio-only).

How can I reduce denials for 90838 claims?

To reduce denials, ensure thorough documentation that clearly distinguishes between E/M and psychotherapy services, verify insurance coverage regularly, obtain necessary pre-authorizations, and use appropriate modifiers for telehealth sessions. Also, be aware of frequency limitations set by different payers and reserve 90838 for situations with clear clinical justification.