Psychiatric Diagnostic Evaluation

90791 – Psychiatric Diagnostic Evaluation

A comprehensive psychiatric evaluation conducted by a licensed mental health professional (psychiatrist, psychologist, LCSW, LPC, etc.) to assess a patient's mental health condition. This is a non-medical assessment that typically involves a structured clinical interview, review of history, mental status examination, and development of a diagnostic impression and treatment plan. It does not include the prescribing of medications.

Important Information

Purpose: To establish an initial diagnosis or re-evaluate an existing diagnosis. Used at the start of a new treatment relationship or when a significant change in clinical status warrants a thorough reassessment. The clinician gathers presenting complaints, psychiatric history, social and developmental history, and current functioning.

Session Duration: Typically 60–90 minutes. There is no specific minimum time requirement, but the evaluation must be comprehensive enough to support diagnostic conclusions.

Documentation: Must include a complete psychiatric history, chief complaint, mental status examination, DSM-5 diagnostic impression, and a treatment plan or referral recommendations. A medical record entry is required; progress notes from ongoing therapy sessions are not sufficient.

Telehealth Modification: Covered via telehealth under most payers including Medicare and Medicaid when delivered via audio-video platforms meeting HIPAA requirements. Append modifier GT (for Medicare) or 95 (commercial plans) as required by the payer.

90792 – Psychiatric Diagnostic Evaluation with Medical Services

Similar to 90791, this is a comprehensive psychiatric diagnostic evaluation, but it includes medical services such as ordering labs, reviewing medical records for physical health conditions, prescribing or adjusting medications, and evaluating physical health factors that interact with mental health. This code is typically used by psychiatrists or other prescribing providers (e.g., psychiatric nurse practitioners).

Important Information

Purpose: To assess a patient's psychiatric condition in the context of their broader medical health, integrating both psychiatric and physical health findings. Used when the evaluating clinician has prescriptive authority and incorporates a medical component into the evaluation.

Session Duration: Typically 60–90 minutes. No hard minimum, but the medical component must be substantial enough to differentiate from 90791.

Documentation: Must include all elements of 90791 (chief complaint, psychiatric history, MSE, DSM-5 diagnosis, treatment plan) PLUS documentation of medical services rendered — medication management, lab orders, review of physical health records, or physical exam findings.

Telehealth Modification: Covered via telehealth under most payers. Apply modifier GT or 95 depending on payer requirements. Note that some states have restrictions on prescribing controlled substances via telehealth; verify state law before billing.

Psychotherapy

90832 – Psychotherapy, 16–37 Minutes

Individual psychotherapy provided for a duration of 16 to 37 minutes. This code reflects a shorter psychotherapy session where a clinician provides evidence-based therapeutic interventions to address mental health conditions. It is used when the clinical need or patient circumstances result in a briefer session.

Important Information

Purpose: To deliver focused therapeutic interventions for patients who benefit from or require shorter sessions (e.g., children, individuals with cognitive limitations, crisis stabilization, or medical settings where time is limited).

Session Duration: 16–37 minutes of face-to-face (or telehealth) psychotherapy. Time must be documented. Sessions shorter than 16 minutes cannot be billed under any psychotherapy code.

Documentation: Must include session start/stop times, therapeutic modality used, clinical interventions, patient response, and progress toward treatment plan goals. A signed treatment plan must be on file.

Telehealth Modification: Covered via telehealth. Append appropriate modifier (GT for Medicare, 95 for commercial). Ensure the platform is HIPAA-compliant and that the patient's location is noted in the record.

90833 – Psychotherapy Add-On, 30 Minutes (with E/M Service)

An add-on code for psychotherapy lasting approximately 30 minutes (16–37 minutes), provided on the same date as an Evaluation and Management (E/M) service by the same provider. This code is used when a prescribing clinician (e.g., psychiatrist) provides both medication management (billed as an E/M) and psychotherapy in the same encounter.

Important Information

Purpose: To capture the psychotherapy component of a combined medication management and therapy visit. Allows a prescribing provider to bill for both the E/M service and the psychotherapy separately within a single appointment.

Session Duration: 16–37 minutes of psychotherapy, in addition to the time spent on the E/M service. Only the psychotherapy time is counted for this add-on.

Documentation: Both the E/M and psychotherapy components must be independently documented. The note must clearly distinguish the therapy portion from the medical management portion, with separate documentation of interventions, patient response, and time.

Telehealth Modification: Can be billed for telehealth encounters when the companion E/M code is also delivered via telehealth. Apply the same modifier (GT or 95) to both codes.

90834 – Psychotherapy, 38–52 Minutes

Individual psychotherapy provided for a duration of 38 to 52 minutes. This is the most commonly billed standard psychotherapy code, representing a typical therapy session. The clinician provides structured, evidence-based therapeutic interventions tailored to the patient's diagnosis and treatment goals.

Important Information

Purpose: Standard individual therapy session. Used across a wide range of diagnoses including depression, anxiety, PTSD, OCD, adjustment disorders, and more. Appropriate for most outpatient psychotherapy encounters.

Session Duration: 38–52 minutes. Time must be documented with start and stop times.

Documentation: Requires documentation of session date and time, presenting concerns addressed, therapeutic techniques used, patient response and progress, risk assessment if applicable, and any changes to the treatment plan.

Telehealth Modification: Widely covered via telehealth by Medicare, Medicaid, and most commercial insurers. Append modifier GT or 95 as required. Confirm state licensure requirements if the patient is located in a different state than the provider.

90836 – Psychotherapy Add-On, 45 Minutes (with E/M Service)

An add-on code for psychotherapy lasting approximately 45 minutes (38–52 minutes), provided on the same date as an Evaluation and Management (E/M) service by the same provider. Like 90833, this is used when a prescribing clinician provides both medication management and psychotherapy in the same encounter, but for a longer therapy component.

Important Information

Purpose: To capture a longer psychotherapy component (45-minute range) within a combined medication management and therapy visit. Used when the psychotherapy portion is clinically significant and extends beyond the 30-minute add-on threshold.

Session Duration: 38–52 minutes of psychotherapy, in addition to E/M time. The total encounter time will be the sum of E/M and therapy time.

Documentation: Must independently document both the E/M and psychotherapy components. The note must clearly separate medical management from therapeutic intervention, with distinct documentation of clinical content and time for each.

Telehealth Modification: Applicable for telehealth visits when the companion E/M code is also delivered via telehealth. Apply modifier GT or 95 to both codes consistently.

90837 – Psychotherapy, 53+ Minutes

Individual psychotherapy for 53 minutes or more. This is the highest-time psychotherapy code and reflects longer, more intensive sessions. It may be used for complex presentations, trauma-focused work, or therapeutic modalities that require extended session lengths (e.g., EMDR, prolonged exposure).

Important Information

Purpose: For patients requiring longer, more intensive therapeutic sessions. Commonly used for trauma processing, complex PTSD, severe depression, or when a therapeutic model (such as EMDR or DBT skills training) requires extended time.

Session Duration: 53 minutes or more. There is no upper time limit, but many payers will scrutinize sessions that are excessively long without clear clinical justification.

Documentation: Must document session time (start/stop), clinical justification for extended duration, modalities used, and patient progress. If trauma-focused, note the specific protocol being followed.

Telehealth Modification: Covered via telehealth under most plans. Append modifier GT or 95. Some payers may require prior authorization for extended sessions — verify before billing.

90838 – Psychotherapy Add-On, 60 Minutes (with E/M Service)

An add-on code for psychotherapy lasting approximately 60 minutes (53+ minutes), provided on the same date as an Evaluation and Management (E/M) service by the same provider. This is the longest psychotherapy add-on code and is used when a prescribing clinician provides an extended psychotherapy session alongside medication management.

Important Information

Purpose: To capture a full 60-minute therapy component within a combined medication management and therapy encounter. Used for complex cases requiring extended psychotherapy in addition to medical management.

Session Duration: 53 minutes or more of psychotherapy, beyond the E/M component. The combined encounter will be notably longer than a standard visit.

Documentation: Full independent documentation required for both the E/M and psychotherapy components. Clearly distinguish therapeutic interventions, time spent, and clinical decision-making for each portion of the visit.

Telehealth Modification: Applicable for telehealth visits when the companion E/M code is delivered via telehealth. Apply modifier GT or 95 to both codes.

90839 – Psychotherapy for Crisis, First 30–74 Minutes

Psychotherapy provided to a patient in a mental health crisis. A crisis is defined as a situation requiring immediate clinical attention due to acute suicidal ideation, self-harm, acute psychiatric decompensation, or other urgent mental health emergencies. This code covers the first 30 to 74 minutes of crisis intervention.

Important Information

Purpose: To stabilize a patient experiencing an acute psychiatric crisis. Crisis psychotherapy involves immediate assessment of safety, de-escalation, safety planning, and coordination of care. It goes beyond standard psychotherapy in urgency and clinical intensity.

Session Duration: 30–74 minutes. For crisis services extending beyond 74 minutes, add-on code 90840 may be billed in addition.

Documentation: Must clearly document the nature of the crisis, the patient's presenting safety concerns, interventions used, safety plan created or reviewed, and disposition. Time must be documented.

Telehealth Modification: Covered via telehealth. Crisis services via telehealth require extra attention to safety planning — clinicians must have a protocol for dispatching emergency services to the patient's location if needed. Document the patient's physical location in every crisis telehealth note.

90840 – Psychotherapy for Crisis, Additional 30 Minutes (Add-On)

An add-on code billed in conjunction with 90839 when a crisis psychotherapy session extends beyond 74 minutes. Each unit of 90840 represents an additional 30 minutes of crisis intervention. It cannot be billed as a standalone code.

Important Information

Purpose: To capture the additional time spent on crisis intervention when a situation requires extended clinical attention beyond the initial 74-minute window.

Session Duration: Each unit = 30 minutes of additional crisis psychotherapy. Multiple units may be billed if clinically justified.

Documentation: Must document the continued crisis intervention, why extended time was necessary, patient status throughout, and final disposition. Must be billed alongside 90839.

Telehealth Modification: Same telehealth rules as 90839 apply. Document continued patient location and safety check-ins throughout the extended session.

Interactive Complexity

90785 – Interactive Complexity (Add-On)

An add-on code used alongside primary psychiatric or psychotherapy service codes to indicate that the encounter involved significant interactive complexity. Interactive complexity refers to specific communication factors that complicate the delivery of the psychiatric procedure, such as using play equipment, physical devices, or interpreters, or when the patient is a young child, has a legal guardian other than a parent present, or there are high levels of caregiver emotion or maladaptive communication.

Important Information

Purpose: To capture the additional clinical effort required when communication with the patient (or those involved in the encounter) is significantly more complex than a standard session. Commonly used in child and adolescent work, interpreter-assisted sessions, and situations involving legally mandated treatment.

Session Duration: No separate time requirement. Billed as an add-on to the primary service code (e.g., 90791, 90792, 90832, 90834, 90837, 90847, 90849, 90853).

Documentation: Must explicitly document the nature of the interactive complexity — e.g., the presence of play therapy, interpreter use, the age of the patient, guardian involvement, or communication barriers that required additional clinical effort.

Telehealth Modification: Can be billed with telehealth encounters when the primary service code is delivered via telehealth and the interactive complexity factors are present and documented. Apply the modifier to the primary code, not to 90785 itself.

Family Psychotherapy

90846 – Family Psychotherapy without Patient Present

Family or conjoint psychotherapy conducted without the identified patient present. The clinician meets with family members or significant others alone — typically to provide psychoeducation, coordinate care strategies, or address family dynamics in a way that is clinically indicated without the patient's direct participation.

Important Information

Purpose: Used when it is clinically beneficial to meet with family members separately from the patient — for example, to provide caregiver coaching for a child with ASD, to support family members of someone with severe mental illness, or to coordinate safety planning.

Session Duration: Typically 50–60 minutes. Time should be documented.

Documentation: Document the clinical rationale for meeting without the patient, who was present, topics discussed, and how the session supports the patient's overall treatment. A treatment plan for the identified patient must still be on file.

Telehealth Modification: Covered via telehealth. The clinician should note the location of all family members participating. Obtain verbal or written consent from all adult participants at the start of the session.

90847 – Family Psychotherapy with Patient Present

Family or conjoint psychotherapy conducted with the identified patient present. The clinician works with the patient and one or more family members or significant others to address relational dynamics, communication patterns, family system issues, and their impact on the patient's mental health.

Important Information

Purpose: To address family system issues that contribute to or maintain the patient's mental health condition. Includes family therapy for eating disorders, adolescent behavioral issues, caregiver relationships, substance use, and communication difficulties.

Session Duration: Typically 50–60 minutes, though no strict time minimum is defined by CPT. Time should be documented.

Documentation: Document all participants present, the family issues addressed, therapeutic interventions, patient and family responses, and goals for future sessions. The identified patient must be present for this code.

Telehealth Modification: Covered via telehealth. Note the location of all participants if they are joining from different sites. HIPAA-compliant platform required. Confirm consent from all adult participants.

90849 – Multiple-Family Group Psychotherapy

Group therapy that involves multiple families participating together. A clinician or co-therapists facilitate a session that includes more than one family unit, focusing on shared experiences, mutual support, and therapeutic intervention across family systems.

Important Information

Purpose: Used in settings where multiple families benefit from shared therapeutic experience — such as family programs within psychiatric hospitals, substance use treatment, or programs for families of adolescents with eating disorders.

Session Duration: Typically 60–90 minutes. Document session time.

Documentation: Document all participants (by family unit), topics addressed, therapeutic interventions, and each identified patient's engagement and progress.

Telehealth Modification: Covered via telehealth in most states. Group telehealth sessions require all participants to have consented and be informed that others are present. Clinicians should use a platform that supports multiple concurrent video participants.

Group Psychotherapy

90853 – Group Psychotherapy (Non-Family)

Psychotherapy provided in a group setting to multiple unrelated patients simultaneously. The clinician facilitates therapeutic interactions among group members, addressing shared mental health concerns using evidence-based group therapy modalities (e.g., CBT group, DBT skills group, process group).

Important Information

Purpose: Group therapy leverages the therapeutic value of peer interaction, shared experiences, and group dynamics to promote healing. Commonly used for depression, anxiety, substance use disorders, grief, and interpersonal issues.

Session Duration: Typically 60–90 minutes. Time must be documented. Groups typically consist of 6–12 participants.

Documentation: Each group member must have their own progress note documenting their individual participation, therapeutic goals addressed, and response to the group session. A single note covering the group is not sufficient.

Telehealth Modification: Covered via telehealth. Each participant must be on a HIPAA-compliant platform. Clinicians must obtain consent from each participant acknowledging that other group members will be visible. Document all participants by name in each session note.

Psychoanalysis

90845 – Psychoanalysis

Psychoanalysis involves intensive, long-term psychotherapy based on psychoanalytic theory and technique, including exploration of the unconscious, transference analysis, free association, and dream analysis. Sessions are typically held multiple times per week over an extended period.

Important Information

Purpose: For patients engaged in long-term, intensive psychoanalytic treatment targeting deep-seated personality patterns, unresolved early conflicts, and chronic psychological difficulties. Typically used in private-pay or specialty settings.

Session Duration: Typically 45–50 minutes per session. No strict CPT-defined time requirement, but sessions are usually consistent in length.

Documentation: Document the psychoanalytic process, key themes explored, transference/countertransference observations, and the patient's progress within the analytic framework.

Telehealth Modification: Reimbursement for psychoanalysis via telehealth varies significantly by payer. Most commercial plans with telehealth benefits cover it, but some psychoanalytic practitioners argue that the in-person relationship is clinically essential. Check with individual payers.

Psychophysiological Therapy

90875 – Individual Psychophysiological Therapy with Biofeedback Training

Individual psychotherapy combined with biofeedback training. The clinician uses biofeedback equipment to help the patient gain awareness of and control over physiological processes (e.g., heart rate, muscle tension, skin temperature) as part of a therapeutic intervention for mental health or psychosomatic conditions.

Important Information

Purpose: Used for anxiety disorders, PTSD, stress-related conditions, chronic pain, headaches, and other conditions where physiological self-regulation is a clinical goal. The biofeedback component provides real-time feedback to support mind-body therapeutic techniques.

Session Duration: Typically 45–60 minutes. Time must be documented.

Documentation: Document the biofeedback modality used, physiological parameters monitored, patient response to training, integration with psychotherapy techniques, and progress toward therapeutic goals.

Telehealth Modification: Biofeedback via telehealth is possible with appropriate remote biofeedback equipment, though it is less common. Coverage varies by payer. Confirm equipment compatibility and payer policy before delivering this service via telehealth.

90876 – Group Psychophysiological Therapy with Biofeedback Training

Group psychotherapy combined with biofeedback training, delivered to multiple patients simultaneously. Similar to 90875 but conducted in a group format, integrating biofeedback technology with group therapeutic processes.

Important Information

Purpose: Used when group biofeedback training is clinically appropriate — for example, in hospital-based stress management programs, chronic pain groups, or anxiety management programs where biofeedback equipment is shared or demonstrated.

Session Duration: Typically 60–90 minutes for group sessions. Document session time.

Documentation: Each participant needs an individual note documenting their physiological responses, progress, and therapeutic participation. Document the biofeedback modality used.

Telehealth Modification: Similar considerations as 90875 for remote biofeedback. Group telehealth biofeedback is technically complex and rarely covered; verify with each payer before attempting.

Pharmacologic Management

90863 – Pharmacologic Management (Add-On with Psychotherapy)

An add-on code used when a prescribing clinician (e.g., psychiatrist) provides medication management in conjunction with a psychotherapy session on the same date of service. It cannot be billed alone and must accompany a psychotherapy code (90832, 90834, or 90837).

Important Information

Purpose: To capture the medication management component when it is provided alongside psychotherapy during the same encounter. For example, a psychiatrist who spends 45 minutes providing therapy AND also reviews and adjusts medication during the same appointment.

Session Duration: No separate time requirement — it is an add-on to the psychotherapy time. The prescribing activity must be distinct and documented.

Documentation: Document the medication review, any changes to prescriptions, patient response to medications, side effects discussed, and clinical reasoning for any adjustments. The therapy portion must also be fully documented under the primary code.

Telehealth Modification: Follows the same telehealth rules as the primary psychotherapy code it accompanies. Prescribing via telehealth is subject to state laws and DEA regulations, especially for controlled substances.

Psychological and Neuropsychological Testing

96130 – Psychological Testing Evaluation Services, First Hour

Covers the first hour of psychological testing evaluation services performed by a psychologist or physician. This includes interpretation of results, clinical decision-making, and preparation of a report. It encompasses tests such as personality assessments, cognitive evaluations, and clinical interviews used in the diagnostic process.

Important Information

Purpose: To evaluate cognitive, emotional, behavioral, and personality functioning for diagnostic clarification, treatment planning, disability determination, educational placement, or forensic purposes.

Session Duration: Billed per hour for the first hour of evaluation time. This covers both administration oversight and interpretation work by the qualified professional.

Documentation: Must include the specific tests administered, interpretation of results, a summary of clinical findings, diagnostic impressions, and treatment or referral recommendations. Raw test data should be retained in the record.

Telehealth Modification: Coverage for remote psychological testing varies significantly by payer. Some tests can be administered via validated telehealth protocols, but not all. Verify payer policy and ensure any remote testing platform is psychometrically validated for the specific instrument.

96131 – Psychological Testing Evaluation Services, Each Additional Hour (Add-On)

An add-on code billed for each additional hour of psychological testing evaluation beyond the first hour (96130). Used when the scope of the evaluation requires more than one hour of professional evaluation and interpretation time.

Important Information

Purpose: Allows accurate billing for comprehensive evaluations (e.g., full psychoeducational assessments, forensic evaluations, or complex differential diagnosis workups) that require extended professional time.

Session Duration: Each unit = 1 additional hour of evaluation time. Must be billed alongside 96130.

Documentation: Documentation must support the need for additional evaluation time and reflect the additional tests interpreted or clinical decisions made during the extended evaluation period.

Telehealth Modification: Same telehealth considerations as 96130 apply. Each additional hour of remote evaluation must be covered under the same payer policy.

96132 – Neuropsychological Testing Evaluation Services, First Hour

Covers the first hour of neuropsychological testing evaluation services by a neuropsychologist or other qualified professional. Neuropsychological testing assesses brain-behavior relationships and is used to evaluate the cognitive impact of neurological conditions, brain injuries, developmental disorders, and psychiatric conditions.

Important Information

Purpose: Used to evaluate memory, attention, executive function, language, visuospatial abilities, and other cognitive domains affected by neurological or psychiatric conditions. Common referral reasons include TBI, dementia, stroke, ADHD, learning disabilities, and seizure disorders.

Session Duration: Billed per hour for the first hour of neuropsychological evaluation. Evaluation time often extends over multiple hours or sessions.

Documentation: Must document the referral question, specific tests used, normative comparisons, clinical interpretation, neuropsychological profile, diagnosis, and recommendations for treatment or rehabilitation.

Telehealth Modification: Remote neuropsychological testing is emerging but limited. Many standardized instruments lack validated telehealth norms. Payer coverage varies. Use only validated digital testing platforms and document the telehealth method used.

96133 – Neuropsychological Testing Evaluation Services, Each Additional Hour (Add-On)

An add-on code billed for each additional hour of neuropsychological testing evaluation beyond the first hour (96132). Neuropsychological evaluations frequently require multiple hours of professional interpretation time due to the breadth of domains assessed.

Important Information

Purpose: Captures additional professional evaluation time for comprehensive neuropsychological batteries that cover multiple cognitive domains and require extensive interpretation and report writing.

Session Duration: Each unit = 1 additional hour of neuropsychological evaluation. Must be billed alongside 96132.

Documentation: Documentation must reflect the additional cognitive domains evaluated, further clinical decision-making, and the cumulative interpretation across all testing hours.

Telehealth Modification: Same considerations as 96132 apply for each additional hour billed remotely.

96136 – Psychological or Neuropsychological Test Administration and Scoring, First 30 Minutes

Covers the first 30 minutes of test administration and scoring performed by a psychologist or physician. This code is used when the qualified professional personally administers and scores psychological or neuropsychological tests, as distinguished from technician-administered testing (which uses 96138).

Important Information

Purpose: For tests that require direct administration and scoring by the credentialed professional — particularly when the testing process itself requires clinical judgment, behavioral observation, or real-time modification based on patient responses.

Session Duration: First 30 minutes of direct test administration and scoring by the qualified professional.

Documentation: Document the specific tests administered, patient behavior during testing, any adaptations made, and scoring results. The professional must be the one administering the tests for this code.

Telehealth Modification: May be used for telehealth-delivered testing when the instrument is validated for remote administration. Document the platform used and patient environment.

96137 – Psychological or Neuropsychological Test Administration and Scoring, Each Additional 30 Minutes (Add-On)

An add-on code for each additional 30 minutes of test administration and scoring beyond the first 30 minutes (96136) by the qualified professional. Used for extended testing sessions requiring more than 30 minutes of direct administration time.

Important Information

Purpose: Captures additional direct testing time when a comprehensive battery requires extended administration by the credentialed professional.

Session Duration: Each unit = 30 minutes of additional test administration and scoring. Must be billed alongside 96136.

Documentation: Document the tests administered during the additional time period, patient cooperation and fatigue factors, and cumulative test results.

Telehealth Modification: Same considerations as 96136 for each additional 30-minute unit of remote administration.

Health Behavior Assessment and Intervention

96156 – Health Behavior Assessment or Re-Assessment

A face-to-face assessment of psychological, behavioral, emotional, cognitive, and social factors affecting a patient's physical health condition. This code is used by health psychologists and behavioral health specialists working with patients who have primary physical diagnoses (not psychiatric diagnoses), such as chronic pain, diabetes, cardiac disease, or cancer.

Important Information

Purpose: To evaluate behavioral and psychological factors influencing a patient's physical health condition, adherence to treatment, health behaviors, and quality of life. Distinct from psychiatric evaluation — the patient does not need a mental health diagnosis to receive this service.

Session Duration: Typically 30–60 minutes for an initial assessment. Time should be documented.

Documentation: Document the physical health condition being addressed, behavioral and psychological factors assessed, clinical findings, and recommendations for intervention. A DSM-5 mental health diagnosis is not required, but the physical health diagnosis should be documented.

Telehealth Modification: Covered via telehealth under most payers. Append modifier GT or 95. Particularly useful for patients with mobility limitations due to chronic conditions.

96158 – Health Behavior Intervention, Individual, First 30 Minutes

Individual face-to-face health behavior intervention focused on modifying psychological, behavioral, emotional, cognitive, and social factors affecting a patient's physical health condition. Interventions may include motivational interviewing, cognitive-behavioral strategies, relaxation techniques, and behavioral activation applied to physical health management.

Important Information

Purpose: To reduce health risk behaviors, improve treatment adherence, and enhance quality of life for patients with chronic or acute physical health conditions. Examples include smoking cessation, diabetes self-management, pain coping strategies, and pre-surgical psychological preparation.

Session Duration: First 30 minutes of individual health behavior intervention. Billed per session.

Documentation: Document the physical health condition being addressed, specific behavioral intervention techniques used, patient response, and goals for ongoing intervention. Must tie interventions to the underlying physical diagnosis.

Telehealth Modification: Covered via telehealth. Append appropriate modifier. Effective for behavior change programs where ongoing remote coaching supports patient health goals.

96159 – Health Behavior Intervention, Individual, Each Additional 15 Minutes (Add-On)

An add-on code for each additional 15 minutes of individual health behavior intervention beyond the first 30 minutes (96158). Used when a session extends beyond the initial 30-minute period.

Important Information

Purpose: To capture additional intervention time when a patient requires more than 30 minutes of individual health behavior coaching or intervention in a single encounter.

Session Duration: Each unit = 15 minutes of additional intervention. Must be billed alongside 96158.

Documentation: Document the additional content covered, patient engagement, and cumulative session time.

Telehealth Modification: Same telehealth considerations as 96158 apply for each additional unit.

96164 – Health Behavior Intervention, Group, First 30 Minutes

Group health behavior intervention focusing on modifying psychological, behavioral, and social factors affecting participants' physical health conditions. Led by a health psychologist or behavioral health clinician, the group format leverages peer support and shared learning.

Important Information

Purpose: For groups of patients managing the same or related physical health conditions — such as chronic pain management groups, cardiac rehabilitation behavioral components, or diabetes education groups with a behavioral focus.

Session Duration: First 30 minutes of group health behavior intervention. Groups typically include multiple participants with related physical health concerns.

Documentation: Document the physical health focus of the group, interventions delivered, and individual participant engagement. Each participant requires a separate note.

Telehealth Modification: Covered via telehealth for group formats when a HIPAA-compliant multi-participant platform is used. Obtain consent from all participants.

96165 – Health Behavior Intervention, Group, Each Additional 15 Minutes (Add-On)

An add-on code for each additional 15 minutes of group health behavior intervention beyond the first 30 minutes (96164). Used for extended group sessions.

Important Information

Purpose: Captures additional group intervention time for longer group health behavior sessions.

Session Duration: Each unit = 15 minutes of additional group intervention. Must be billed alongside 96164.

Documentation: Document additional content covered and continued participant engagement for the extended session time.

Telehealth Modification: Same considerations as 96164 for additional units.

96167 – Health Behavior Intervention, Family (with Patient Present), First 30 Minutes

Family health behavior intervention conducted with the patient present, targeting behavioral and psychological factors that affect the patient's physical health condition. The family members participate in the intervention alongside the patient.

Important Information

Purpose: To engage family members in supporting the patient's management of a physical health condition — for example, helping family members of a diabetic patient understand dietary support, or engaging family in a chronic pain patient's rehabilitation process.

Session Duration: First 30 minutes of family health behavior intervention with patient present.

Documentation: Document all participants present, the physical health condition being addressed, behavioral strategies discussed, and the family's role in supporting the patient's health goals.

Telehealth Modification: Covered via telehealth. Confirm all family members and the patient are present and have consented to the session format.

96168 – Health Behavior Intervention, Family (with Patient Present), Each Additional 15 Minutes (Add-On)

An add-on code for each additional 15 minutes of family health behavior intervention with the patient present, beyond the first 30 minutes (96167).

Important Information

Purpose: Captures additional family health behavior intervention time when a single session requires extended engagement.

Session Duration: Each unit = 15 minutes of additional family intervention. Must be billed alongside 96167.

Documentation: Document additional content covered and continued family and patient engagement.

Telehealth Modification: Same telehealth considerations as 96167.

Evaluation and Management (Mental Health Focus)

99202–99215 – Evaluation and Management with Mental Health Focus

Evaluation and Management codes (99202–99215) are general medical visit codes frequently used by psychiatrists and primary care providers managing mental health conditions, especially when the visit involves significant medical decision-making. 99202–99205 are for new patients; 99211–99215 are for established patients. They are used in place of or alongside psychiatric codes depending on the service rendered.

Important Information

Purpose: Used when the encounter is primarily structured as a medical evaluation rather than psychotherapy — such as medication management visits, psychiatric check-ins without psychotherapy, or primary care management of depression and anxiety. The level is determined by medical decision-making complexity or total time.

Session Duration: Time-based billing is available. Levels range from 99202 (15–29 min) to 99205/99215 (40–54 min and beyond for highest complexity). Alternatively, level is based on Medical Decision Making (MDM) complexity.

Documentation: Must document presenting problems, relevant history, clinical findings, assessment, and plan. For time-based billing, document total clinician time on the date of service. For MDM-based, document the number and complexity of problems addressed.

Telehealth Modification: All E/M codes are covered via telehealth for both Medicare and most commercial payers. Apply modifier GT or 95 as required. Audio-only visits have separate modifier requirements (modifier 93 for Medicare).

Telehealth and Remote Services

G2010 – Remote Evaluation of Patient-Submitted Video/Images

A HCPCS code for the remote evaluation of recorded video or images submitted by an established patient. The clinician reviews patient-submitted audiovisual information (such as photos or short video clips of a skin condition, behavioral episode, or physical symptom) and provides a clinical decision without requiring a full office visit.

Important Information

Purpose: Allows clinicians to evaluate patient-submitted recordings or images asynchronously (store-and-forward), reducing the need for unnecessary in-person visits. Useful for brief clinical check-ins triggered by patient-reported symptoms.

Session Duration: No minimum time defined. The provider must spend sufficient time to render a clinical decision. The review should occur within 24 business hours of submission.

Documentation: Document what was reviewed, the clinical decision made, whether a follow-up visit was ordered, and the date of review. The submission must be from an established patient.

Telehealth Modification: This is inherently a remote service. No modifier is needed as the code is designed for asynchronous telehealth. Ensure the patient's submission platform is HIPAA-compliant.

G2012 – Brief Communication Technology-Based Service (Virtual Check-In)

A HCPCS code for brief virtual check-in services between a clinician and an established patient, conducted via telephone or other real-time communication technology. The check-in is not related to a medical visit in the previous 7 days and does not result in a more formal E/M visit within the next 24 hours.

Important Information

Purpose: To allow brief clinical consultations outside of formal office visits — addressing quick questions, medication concerns, or minor changes in symptoms that do not warrant a full encounter. Reduces patient burden while maintaining clinical contact.

Session Duration: 5–10 minutes. For longer interactions, a full E/M or psychotherapy code may be more appropriate.

Documentation: Document the date and method of communication, the clinical concern addressed, the clinician's assessment, and outcome (e.g., whether a formal visit was scheduled). Must be for an established patient.

Telehealth Modification: This is a telehealth-native code. No additional modifier required. Must be conducted by the billing provider, not support staff, to qualify.

Case Management and Collaborative Care

99484 – Care Management for Behavioral Health Conditions

A monthly care management code for patients with a behavioral health condition receiving care management services by clinical staff under the supervision of the billing provider. The services include monthly care plan updates, coordination with the care team, patient outreach, and behavioral health monitoring. At least 20 minutes of care management time must occur in the calendar month.

Important Information

Purpose: Designed for primary care or integrated care settings managing behavioral health conditions alongside physical health. Supports care coordination for patients with depression, anxiety, PTSD, or substance use disorders who are managed collaboratively.

Session Duration: At least 20 minutes of care management time per calendar month. Time is cumulative and does not need to occur in a single encounter.

Documentation: Document all care management activities performed during the month, total time, staff involved, care plan updates, patient contact attempts, and coordination activities. A behavioral health diagnosis must be documented.

Telehealth Modification: Care management activities (phone calls, care coordination, outreach) may be conducted remotely. This is not a face-to-face code, so standard telehealth modifier rules do not apply. Confirm payer-specific rules for remote care management.

99492 – Initial Psychiatric Collaborative Care Management, First 70 Minutes

The initial monthly billing code for psychiatric Collaborative Care Model (CoCM) services. The CoCM is an evidence-based integrated care model in which a behavioral health care manager, a consulting psychiatrist, and a primary care provider collaborate to manage patients with behavioral health conditions in a primary care setting. This code covers the first month and the first 70 minutes of care manager time.

Important Information

Purpose: To support the delivery of the Collaborative Care Model in the first month of a patient's enrollment. Includes care manager activities, psychiatric caseload consultation (registry review), and systematic outcome tracking using validated measures.

Session Duration: First 70 minutes of behavioral health care manager time within the first calendar month. Time is cumulative across the month.

Documentation: Document care manager activities, psychiatric caseload review sessions, use of a patient registry, validated outcome measures used (e.g., PHQ-9, GAD-7), and the treatment-to-target approach. The consulting psychiatrist must document their caseload consultation.

Telehealth Modification: The CoCM is inherently a care coordination model. Patient-facing components may be telehealth-eligible; non-face-to-face care coordination does not require telehealth modifiers. Confirm payer guidance on CoCM telehealth implementation.

99493 – Subsequent Psychiatric Collaborative Care Management, First 60 Minutes

The subsequent monthly billing code for psychiatric Collaborative Care Model services, used in months after the initial month (billed under 99492). Covers the first 60 minutes of care manager time in each subsequent calendar month.

Important Information

Purpose: Ongoing monthly billing for CoCM services after the initial month. Supports continued collaborative psychiatric care, ongoing outcome tracking, treatment adjustment, and care coordination for patients enrolled in a CoCM program.

Session Duration: First 60 minutes of behavioral health care manager time per subsequent calendar month.

Documentation: Same documentation requirements as 99492 — care manager activities, psychiatric registry review, validated outcome measures, and treatment adjustments. Progress toward treatment targets should be documented monthly.

Telehealth Modification: Same CoCM telehealth considerations as 99492.

99494 – Additional 30 Minutes of Collaborative Care Management (Add-On)

An add-on code for each additional 30 minutes of psychiatric Collaborative Care Model care management time beyond the initial time thresholds in 99492 or 99493. Used in complex months requiring extended care manager engagement.

Important Information

Purpose: Captures additional care manager time in months where patient complexity, care coordination challenges, or clinical deterioration requires more than the standard monthly time allocation.

Session Duration: Each unit = 30 additional minutes of care manager time. Must be billed alongside 99492 or 99493.

Documentation: Document the additional care management activities performed and clinical justification for the extended time — such as a psychiatric crisis, care transition, or significant change in the patient's status.

Telehealth Modification: Same CoCM telehealth considerations as primary codes.

Substance Use Disorder Services (HCPCS)

H0001 – Alcohol and/or Drug Assessment

A HCPCS Level II code for a comprehensive assessment of an individual's alcohol and/or drug use. Includes a clinical interview, substance use history, evaluation of impact on functioning, and development of an individualized treatment plan. Commonly used in Medicaid-funded substance use disorder programs.

Important Information

Purpose: To establish a diagnosis, determine the level of care needed, and develop a treatment plan for individuals with substance use disorders. Required as the initial step in most substance use treatment programs.

Session Duration: Typically 60–90 minutes for a full assessment. Varies by payer and state Medicaid program.

Documentation: Document substance use history (type, frequency, quantity), last use, prior treatment history, medical and psychiatric comorbidities, social determinants of health, and recommended level of care (using ASAM criteria or similar).

Telehealth Modification: Telehealth coverage for H0001 varies by state Medicaid program. Many states expanded telehealth for SUD services post-2020. Confirm your state's current policy.

H0004 – Behavioral Health Counseling and Therapy, per 15 Minutes

A HCPCS code for behavioral health counseling and therapy billed in 15-minute units. Used primarily in Medicaid-funded settings for individual counseling related to mental health or substance use disorders.

Important Information

Purpose: To provide individual therapeutic counseling for mental health or substance use conditions in community-based and Medicaid-funded settings. The 15-minute billing unit accommodates a range of session lengths.

Session Duration: Billed per 15 minutes of service. Document the number of units and total service time.

Documentation: Document session date, start/stop time, total units billed, therapeutic interventions, patient response, and progress toward treatment goals.

Telehealth Modification: Varies by state Medicaid policy. Most states that have expanded SUD telehealth cover H0004 for remote delivery. Apply state-specific telehealth modifiers as required.

H0005 – Alcohol and/or Drug Group Counseling by a Clinician

A HCPCS code for group counseling related to alcohol and/or drug use disorders, delivered by a licensed clinician. Used in substance use treatment programs, outpatient SUD clinics, and Medicaid-funded settings.

Important Information

Purpose: To provide group-based therapeutic support and evidence-based intervention for individuals in substance use disorder treatment. Group format supports peer accountability, shared coping strategies, and cost-effective service delivery.

Session Duration: Typically 60–90 minutes per group session. Billing and time requirements vary by state Medicaid program.

Documentation: Document group session date, participants (individually), topics addressed, and each member's engagement and progress. Individual progress notes are required for each participant.

Telehealth Modification: Coverage varies by state. Many states permit group SUD counseling via telehealth. Ensure all participants are on a HIPAA-compliant platform and have consented to the group telehealth format.

Other HCPCS Mental Health and Community Support Services

H2011 – Crisis Intervention Service, per 15 Minutes

A HCPCS code for crisis intervention services billed in 15-minute units. Used in Medicaid-funded settings to provide stabilization, de-escalation, and safety planning for individuals experiencing an acute mental health or substance use crisis.

Important Information

Purpose: To provide immediate, intensive intervention for individuals in psychiatric or substance use crisis, preventing escalation and hospitalization. Commonly used by mobile crisis teams, crisis stabilization units, and community mental health centers.

Session Duration: Billed per 15 minutes. Document total units and service time. Crisis intervention may occur over multiple hours in complex situations.

Documentation: Document nature of the crisis, safety risk assessment, interventions provided, patient response, safety plan, and disposition. Each 15-minute unit should be accounted for in the record.

Telehealth Modification: Varies by state Medicaid program. Remote crisis intervention (by phone or video) is widely recognized as clinically effective, and many states have expanded telehealth coverage for H2011. Document the patient's physical location for all remote crisis services.

H2014 – Skills Training and Development, per 15 Minutes

A HCPCS code for skills training and development services billed in 15-minute units. Used in Medicaid-funded settings to build functional, social, and independent living skills for individuals with serious mental illness or developmental disabilities.

Important Information

Purpose: To teach practical life skills — such as budgeting, communication, medication management, hygiene, and community navigation — that support independence and community integration for individuals with chronic mental health conditions.

Session Duration: Billed per 15 minutes. Services may be provided individually or in group settings, in the community or in a clinical setting.

Documentation: Document the specific skill being addressed, training activities, patient participation and progress, and relevance to the individual's treatment plan and recovery goals.

Telehealth Modification: Coverage varies by state. Some skills training (particularly community-based activities) cannot be replicated via telehealth. Remote delivery of skills coaching is covered in many states for appropriate skill domains.

H2019 – Therapeutic Behavioral Services, per 15 Minutes

A HCPCS code for therapeutic behavioral services billed in 15-minute units. Used primarily for children and adolescents with serious emotional disturbances (SED) or behavioral challenges who require intensive, individualized behavioral support beyond standard therapy.

Important Information

Purpose: To address severe behavioral challenges in children and adolescents through individualized, behaviorally-based interventions. Often used in conjunction with school-based services, residential programs, or intensive community-based mental health programs.

Session Duration: Billed per 15 minutes. Services are typically delivered in the home, school, or community setting.

Documentation: Document the specific behavioral targets, intervention strategies, patient/family response, and progress toward behavioral goals. A behavior support plan is typically required.

Telehealth Modification: Varies by state Medicaid program. Community- and school-based components may not be deliverable remotely. Confirm state policy for remote behavioral services.

T1015 – Clinic Visit/Encounter, All Inclusive (FQHC/RHC)

A HCPCS code used in Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) to capture an all-inclusive behavioral health encounter under the Prospective Payment System (PPS) rate. It bundles multiple behavioral health services delivered during a single visit into one billable unit.

Important Information

Purpose: Used in FQHC and RHC settings to bill for the full scope of a behavioral health encounter as a single bundled rate, rather than itemizing individual CPT codes. Mental health clinicians in these settings should understand how their services are captured under T1015.

Session Duration: Covers the full encounter regardless of individual service duration.

Documentation: Documentation must reflect the full scope of services provided during the encounter — assessment, therapy, care coordination — as this code bundles everything into one billable unit.

Telehealth Modification: Telehealth encounters at FQHCs and RHCs qualify for T1015 billing under Medicare and most Medicaid programs, particularly following expanded telehealth rules post-2020. Confirm with your state Medicaid agency.