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90853 CPT Code: A Complete Guide for Therapists Billing Group Therapy

Stanley Efrem

Mar 13, 2025

Therapists can expect a reimbursement rate of $28.14 for group therapy sessions under CPT code 90853 in 2025. This rate shows steady growth from previous years, but getting maximum revenue depends on meeting specific billing requirements.

Medicare has strict rules for group therapy sessions. Groups must stay limited to 10 participants and run for 45-60 minutes. Each client must have their own treatment plan with unique goals. Proper documentation is vital to get claims approved. Your practice will receive appropriate compensation when you apply CPT code 90853 correctly for anxiety, depression, or substance abuse group sessions.

This piece covers everything you should know about billing group therapy sessions the right way. You'll learn about documentation needs, insurance verification, and common challenges that might come up.

Understanding CPT Code 90853 for Group Therapy

The Current Procedural Terminology (CPT) code 90853 represents psychotherapy services that healthcare providers deliver to multiple patients in a group setting [1]. The American Medical Association has managed to keep this code under the category of Other Psychotherapy Procedures [1].

What is CPT code 90853?

CPT code 90853 describes group psychotherapy sessions where patients engage in interpersonal interactions and support each other [2]. These sessions typically last between 45 to 60 minutes [1]. Participants share similar psychological issues but don't know each other before starting therapy [1].

How 90853 is different from other therapy codes

The biggest difference exists between CPT codes 90853 and 90849. CPT code 90853 covers general group psychotherapy, but 90849 specifically handles multiple-family group sessions [3]. CPT code 90853 sessions include individual clients exclusively, but 90849 brings in family members [3]. Medicare generally covers 90853 but doesn't cover 90849 - that's another key distinction [2].

Healthcare providers can use this code among other therapy codes to boost billing accuracy. To cite an instance, the interactive complexity add-on code (+90785) works with 90853 if medical necessity exists [4]. This additional code applies in situations such as:

Maladaptive communication making service delivery complex
Caregiver emotions interfering with treatment plans
Mandatory reporting situations
Need for physical devices in non-native language delivery

When to use the 90853 CPT code

Healthcare providers should use CPT code 90853 for therapy sessions that focus on specific mental health concerns like:

Anxiety
Depression
Panic disorder
Substance abuse
Chronic pain management
Grief counseling [2]

The code comes with specific requirements. Groups must have at least three participants [6]. Medicare guidelines limit sessions to ten participants maximum. Providers can bill this code once daily per patient, though patients can receive both group and individual therapy on the same day.

Each participant needs their own treatment plan and diagnosis code for proper billing. Documentation should capture the group's focus, achieved goals, and how each person responds to therapy. Detailed record-keeping will give accurate billing and help track each participant's progress during treatment.

Essential Requirements for Billing Group Therapy

Billing success in group therapy depends on following Medicare and insurance providers' specific guidelines. Proper reimbursement and healthcare regulation compliance rely on a clear understanding of these requirements.

Group size limitations and session length

Group therapy sessions need the right number of participants. Medicare guidelines require a minimum of three participants, and groups can't exceed 10 clients per session [6]. These sessions usually last 45 to 60 minutes [7]. Some Medicare Administrative Contractors might set different group sizes and limit groups to four patients [8].

Provider qualification requirements

CPT code 90853 billing rights belong only to licensed mental health professionals. These qualified providers include:

Licensed Clinical Social Workers (LCSW)
Licensed Professional Counselors (LPC)
Licensed Mental Health Counselors (LMHC)
Licensed Marriage Family Therapists (LMFT)
Clinical Psychologists (PhD or PsyD)
Psychiatrists (MD) [2]

Documentation necessities for 90853

Documentation serves as the life-blood of successful billing. Each session's records must show:

Date, duration, and participant information
Individual treatment plans and unique goals for each client
Medical necessity justification
Summary of therapeutic interventions
Progress notes that detail individual responses

Medicare and insurance-specific requirements

Insurance requirements vary substantially between providers. You should verify your patient's insurance coverage for group therapy before starting services [10]. Prior authorization might be needed since some insurance plans don't see group therapy as a routine outpatient mental health service [2].

Medicare policies differ based on treatment settings. Inpatient rehabilitation facilities must keep groups of 2-6 patients under Part A [8]. Skilled nursing facilities can use only 25% of total treatment time for group therapy during an episode [8]. Medicare allows billing of interactive complexity add-on code (+90785) with 90853 when medical necessity exists [4].

Psychotherapy codes work in all settings since site of service restrictions don't apply [4]. Your claim approval and timely reimbursement depend on following each insurance provider's specific requirements.

Step-by-Step Billing Process for CPT 90853

Billing accuracy is crucial to run a successful group therapy practice. A systematic approach will give a proper reimbursement and reduce claim denials.

Verifying insurance coverage for group therapy

You should call the customer service number on your client's insurance card first. The verification process needs your Tax ID and NPI to check network status [11]. You need to ask about:

Mental health outpatient provider benefits
Patient's deductible, copay, and coinsurance
Claims submission addresses
Authorization requirements for CPT code 90853

Proper documentation techniques

Your session records should include:

Start and end times of each session
Names of all participants present
Group's therapeutic goals and interventions used
Individual progress notes for each client [12]

Your documentation should prove medical necessity and show a clear connection between the group therapy session and each patient's diagnosis [13]. Standardized templates are a great way to get consistent and complete documentation for all sessions.

Submitting claims with the correct modifiers

Insurance companies usually ask providers to use clearinghouses for claim submissions [11]. Pick a HIPAA-compliant clearinghouse that provides:

Immediate claim tracking
Strong customer service
User-friendly interface
Integration with your EMR system

Sometimes, you might need to use modifier-59 to show separate services when billing for both individual and group therapy on the same day [14]. Each insurance provider has specific modifier requirements that you should verify.

Tracking and following up on claims

You should watch claims through your clearinghouse portal to spot potential issues early. Insurance companies give a 90-day timely filing window [15]. Quick action on denials means you should:

Check if the denial happened at the clearinghouse or insurance level
Verify claim receipt with the insurance company
Learn the specific reason for denial
Refile corrected claims as needed
Submit necessary appeal forms when required [15]

An EMR system that works with your clearinghouse will streamline the billing process and cut down manual entry errors [16]. This setup helps you track claims status and follow up on pending reimbursements quickly.

Common Challenges and Solutions When Billing 90853

Billing issues with CPT code 90853 stem from complex insurance requirements and documentation standards. A good grasp of these challenges and their solutions helps your practice maintain steady revenue.

Denied claims troubleshooting

Data from the Healthcare Financial Management Association shows that clinics can cut denials by 50% when they verify insurance eligibility upfront [17]. Claims might still get rejected though. Here are the common reasons:

Non-therapeutic activities billed under 90853
Incomplete documentation for individual participants
Missing medical necessity justification
Incorrect participant counts

The best way to handle denied claims starts with checking the insurance company's specific reason. You should then gather supporting documents that address the denial and submit an appeal with solid evidence of medical necessity and proper service delivery.

Handling partial payments

Different insurance providers have their own coverage policies for group therapy, which leads to varying patient costs [6]. Here's how you can handle partial payments well:

Set clear payment policies upfront
Use consent forms to inform clients about uncovered charges
Document how each session helps treatment goals
Keep detailed records of individual progress [18]

Managing multiple insurance types in one group

Groups with participants who have different insurance plans need extra attention. Each insurance company may have specific rules about:

Documentation standards
Session length specifications
Group size limitations
Prior authorization needs [3]

These strategies will help streamline your billing across multiple insurers:

Your records should meet the strictest requirements among all insurance providers involved. Time-tracking features in your Electronic Health Record (EHR) system will help document sessions accurately. Regular audits of your billing practices ensure you follow each insurer's guidelines [6].

Note that Medicare policies don't allow certain activities under CPT code 90853 billing, such as group meals, social interaction, grooming instruction, and recreational therapies [18]. You can avoid billing complications by watching these exclusions closely and keeping detailed records across different insurance types.

Conclusion

Group therapy billing just needs careful attention and a full picture of CPT code 90853 requirements. Managing multiple insurance types and documentation can feel overwhelming at first. But proper preparation makes everything easier to handle.

Medicare's specific guidelines about group size, session duration, and documentation create the foundation for clean claims. Your detailed records for each participant, insurance coverage verification, and proper billing procedures will reduce claim denials by a lot.

Each group therapy session needs unique treatment plans and progress notes for individual participants. The quickest way to get appropriate reimbursement is to stay updated with insurance requirements and use good tracking systems. This knowledge about CPT code 90853 helps you provide and bill for group therapy sessions confidently while following healthcare regulations.

FAQs

What is CPT code 90853 used for in therapy?

CPT code 90853 is used for billing group psychotherapy sessions. It covers therapy provided to multiple patients in a group setting, typically lasting 45-60 minutes, where participants share similar psychological issues but are not previously acquainted.

How many participants are allowed in a group therapy session billed under 90853?

For billing under CPT code 90853, group therapy sessions must have a minimum of three participants. Medicare guidelines specify a maximum of ten participants per session, though some Medicare Administrative Contractors may limit groups to four patients.

Can therapists bill for both individual and group therapy on the same day?

Yes, therapists can bill for both individual and group therapy services on the same day for a patient. However, CPT code 90853 can only be billed once per day per patient. In some cases, a modifier may be required to indicate separate services.

What documentation is required for billing group therapy sessions?

Essential documentation for billing group therapy includes the date, duration, and participant information, individual treatment plans and goals for each client, medical necessity justification, a summary of therapeutic interventions, and progress notes detailing individual responses to the therapy.

How can therapists handle denied claims for group therapy sessions?

To handle denied claims, therapists should review the specific reason provided by the insurance company, gather supporting documentation addressing the denial reason, and submit an appeal with thorough evidence of medical necessity and proper service delivery. Verifying insurance eligibility upfront can significantly reduce denials.