The three psychotherapy add-on codes: choosing between 90833, 90836 and 90838
Three codes, one variable. 90833, 90836 and 90838 describe the same service, psychotherapy delivered alongside a separate evaluation and management visit, at three lengths. What moves you between them is how many minutes of psychotherapy you actually did.
That sounds like the easiest decision in psychiatric billing. In practice it is reliably botched, because the minutes clinicians count are the wrong minutes: the whole appointment, the record review before the patient walked in, the note written at nine that night. None of that belongs in the add-on.
This guide is about the choice. For a line by line annotated note on the most common pairing, read the 90833 note example, and for whether a 99214 and a 90833 can sit on the same claim, see billing 99214 with 90833. Here we decide which tier the visit earned.
The family at a glance
All three are reported only in addition to a qualifying evaluation and management service, performed and documented by the same clinician in the same encounter.
| Code | Psychotherapy time reported | Reference time published with the code |
|---|---|---|
| 90833 | 16 to 37 minutes | 30 minutes |
| 90836 | 38 to 52 minutes | 45 minutes |
| 90838 | 53 minutes or more | 60 minutes |
CPT is a registered trademark of the American Medical Association. Descriptors here are paraphrased, and the current code set carries the official language.
Coding conventions change with each annual code set, and payers and state Medicaid programs publish their own policies on who may report these codes and what documentation they expect. What follows is the general framework, not your contracts. Verify against your own payer policies and compliance resource before changing how you bill.
The bands in the second column are published with the codes rather than derived here. Two things set them. Psychotherapy of less than 16 minutes is not separately reported, which fixes the floor. Each upper boundary then sits halfway between adjacent reference times: halfway between 30 and 45 is 37.5, so 90836 begins at 38, and halfway between 45 and 60 is 52.5, so 90838 begins at 53. The arithmetic is only a way to remember the published ranges.
Fourteen minutes of supportive work is real clinical work, but with no add-on to report it folds into the E/M and appears nowhere else on the claim.
The word "add-on" is doing real work here
These three codes cannot stand alone. Several consequences follow, and each shows up in denials:
- Never bill them by themselves. A claim with 90836 and no E/M line will generally not be paid.
- Never pair them with the standalone psychotherapy codes. 90832, 90834 and 90837 are a different family, described in the standalone psychotherapy code guide. With no separately identifiable medical evaluation and management, you are in that family, not this one.
- Never attach them to the intake codes. 90791 and 90792 are diagnostic evaluations, not E/M services in this sense, and the add-ons do not attach to them.
- One unit per session. You do not report 90833 twice for a long visit or stack it on 90836. The tiers are mutually exclusive.
- Modifier 25 is not the joint. These are add-on codes rather than separately reportable procedures, so modifier 25 is not what attaches them to the E/M. A number of plans still reject the E/M line without it, and the denial reason tells you which rule applied.
Not every E/M code qualifies as the primary service. The add-ons attach to office and other outpatient visits, hospital inpatient and observation care, consultations, nursing facility services, and home or residence services. They do not attach to emergency department E/M codes, and prolonged service time add-ons are out as well, since the E/M cannot be leveled by time when an add-on is reported. Check the pairing list in your code set before building a claim outside the office.
90785 for interactive complexity is the add-on most often reported alongside this pair, when the specific complicating factors are present and documented. Other same-date services, such as brief screening instrument administration and scoring, follow their own rules and payer policies.
How the add-on time is counted
Add-on time is psychotherapy time only: time in direct, real-time contact with the patient delivering psychotherapy, in person or over an approved interactive telehealth connection, separate and distinct from the work that constitutes the E/M service. It is not the length of the appointment slot.
| Counts toward the add-on | Does not count |
|---|---|
| Direct, real-time psychotherapy using a recognized therapeutic approach | History taking for the medical evaluation, review of systems, medication history |
| Structured intervention: cognitive restructuring, exposure planning, behavioral activation, skills coaching, psychodynamic work | Mental status examination performed as part of the E/M |
| Processing the patient's response to that intervention in session | Discussion of medication risks, benefits and side effects, and consent |
| Assigning and reviewing between session work that is part of the therapy | Reviewing labs, outside records or prior notes |
| Note writing, ordering, prescribing, care coordination, calls after the visit | |
| Time the patient spent waiting, on forms or screeners |
Two things follow. First, the medication conversation is E/M work. A twenty minute visit in which fifteen went to a cross taper discussion is a good visit, and it does not contain fifteen minutes of psychotherapy.
Second, screening instruments do not buy add-on time. The patient's own time completing a PHQ-9 or an AUDIT-C is neither E/M nor psychotherapy time. Your review and interpretation of the results is E/M work, not add-on time, and whether administration and scoring is separately reportable at all depends on payer policy. Unit limits per date are common, and separately reported scoring time cannot also count toward E/M total time.
Time is counted the same way in a video visit as in the office: what changes is the place of service, the modifier and the technology attestation, not the arithmetic. What varies is coverage: whether a plan pays a psychotherapy add-on delivered by video, and whether an audio-only encounter qualifies, is a payer-by-payer and state-by-state question that has changed more than once. Check the policy before the visit, not after the denial. Mechanics are in telehealth psychiatry documentation.
Select the E/M level by medical decision making, never by time
E/M levels in most categories can generally be chosen either by total time on the date of the encounter or by medical decision making. The moment you report a psychotherapy add-on, that choice collapses to one option.
The logic is simple. The minutes you assign to psychotherapy are already accounted for by the add-on, and you cannot spend them again on a time based E/M level. So the E/M level rests on medical decision making: the problems addressed and their complexity, the data reviewed and analyzed, and the risk from the management options considered.
That makes the therapy tier and the E/M level independent. A 90838 does not push you to a 99215, and a 16 minute 90833 does not hold you down to a 99213. I have made both errors myself, in the same month. Two poorly controlled chronic illnesses and a medication change carry the same medical decision making whether the psychotherapy ran eighteen minutes or fifty five.
What the note has to show
Two services means two footprints, and the note should show where one ends and the other begins. On the E/M side, the reader should see the problems addressed, the data considered, the risk weighed and the decision made, with the reasoning visible rather than asserted.
On the psychotherapy side, four elements carry the weight:
- Time. Total psychotherapy minutes, stated explicitly. Start and stop times are stronger, and some payer policies expect them.
- Modality. Name the approach. "Supportive therapy provided" is thin. "CBT, cognitive restructuring of catastrophic appraisals" is not.
- Target and content. What the intervention aimed at, tied to a goal in the treatment plan. Measurable goals make this paragraph easier to write.
- Response. What the patient did with it in the room, and what comes next.
FICTIONAL EXAMPLE NOTE, EXCERPT ONLY
Details below are invented for illustration and do not describe a real patient.
CHIEF COMPLAINT
Follow up for recurrent depression and panic attacks. "The mornings are still the worst part."
HISTORY OF PRESENT ILLNESS
Marcus is a 42 year old man with recurrent major depressive disorder and panic disorder, seen at four week interval. Sertraline 100 mg daily, adherent. Sleep improved to six hours nightly. Two panic attacks since last visit, both on the highway, down from five. Denies suicidal ideation, plan or intent. No new medical problems or medications from other prescribers. Mild delayed ejaculation, tolerable, no change wanted for this reason.
ASSESSMENT
Recurrent major depressive disorder, partial response, improving. Panic disorder with situational avoidance of highway driving, now the primary functional limitation. Sexual side effect mild, patient declines intervention. A sertraline increase would target residual panic frequency at the cost of a side effect he is willing to live with, and the four week trajectory argues for holding the dose.
PLAN
Continue sertraline 100 mg daily. Dose increase deferred given ongoing improvement and the side effect profile. Discussed increasing to 150 mg next visit if panic frequency plateaus, including the likelihood of worsening the sexual side effect. Return in four weeks. Reviewed when to call the office sooner, and reviewed use of the 988 Suicide and Crisis Lifeline between visits.
PSYCHOTHERAPY
Psychotherapy time 41 minutes, from 10:14 to 10:55, separate and distinct from the evaluation and management service documented above. These minutes were not counted toward that service.
CBT with an exposure focus. Built a driving exposure hierarchy with Marcus, from low traffic surface streets through a two exit highway segment. Identified his central catastrophic appraisal, that a panic attack while driving means losing control of the car, and tested it against his history of eleven attacks with no loss of control. He resisted the reframe at first, then generated the counterevidence himself. Screened for sedation, syncope and driving safety before assigning in vivo work, and Marcus agreed to the plan and to stopping if symptoms escalate. Assigned two surface street exposures with a brief log of anticipated and actual anxiety. Target goal: independent highway driving to work by the twelve week review.
Why 90838 draws more scrutiny
Reporting 90838 asserts at least 53 minutes of psychotherapy on top of a separately documented evaluation and management service. That puts the encounter well past an hour, and anyone reviewing a set of claims can do the arithmetic.
In my experience, and in the payer policies I have read, the patterns that attract questions are:
- 90838 on a high proportion of a clinician's visits, which can imply a schedule that would be hard to fit into a working day.
- Psychotherapy minutes that equal or exceed the appointment length, leaving no room for the E/M service the add-on requires.
- A psychotherapy paragraph identical across visits, which reads as a template rather than an hour of clinical work.
- A thin E/M component, which raises the question of whether this belonged in the standalone family.
None of that makes 90838 improper. Long sessions happen, especially in trauma focused work, early phase treatment and complex cases. It does mean the note should look like an hour of work: distinct content, a named modality, a documented response, a plan that has moved. If the same note would be equally true of a 25 minute session, the tier is exposed.
The longest sessions also tend to be the ones where risk is on the table. If risk is present, the note should show what you assessed, what you concluded and what safety information you gave, including the 988 Suicide and Crisis Lifeline.
A decision path you can run in thirty seconds
- Was there a separately identifiable E/M service? If no, stop. You are in the 90832, 90834 or 90837 family.
- Time the psychotherapy directly. Note when it started and when it stopped. Without that, subtracting the E/M work from the appointment gives a ceiling rather than a total, and anything that was neither E/M nor structured psychotherapy comes out too.
- Is what remains at least 16 minutes of psychotherapy? If no, report the E/M alone, selected by medical decision making or by total time on the date of the encounter, counting only activities that fall within the E/M time definition.
- Place the minutes in a band. 16 to 37 is 90833. 38 to 52 is 90836. 53 or more is 90838.
- Select the E/M level by medical decision making, independently, and write the minutes into the note before you close it.
The habit that makes step five painless is writing the start and stop time in the room rather than reconstructing later. Reconstructed minutes drift upward. Mine did, until I started writing the stop time before the patient left.
When the standalone family is the right answer instead
If the encounter was psychotherapy and only psychotherapy, the add-on family is the wrong tool no matter how long the session ran. That is what 90832, 90834 and 90837 exist for, and their bands describe the entire service rather than a piece of it.
The most common version I run into is a prescriber who does therapy for the full session, glances at the medication list, changes nothing, and bills an E/M with a 90836. A glance at an unchanged medication list will generally not, on its own, support a separately identifiable evaluation and management service. The question is whether medically necessary medical work was done and documented, not whether a medication list was opened.
The reverse error is also common: a bifurcated visit reported as a single standalone therapy code, understating the medical work. Both come from not deciding at the top of the visit what kind of visit it is.
Frequently asked questions
What if the psychotherapy ran 15 minutes?
No add-on. The work folds into the E/M service, and the E/M level may then be selected by medical decision making or by total time on the date of the encounter, whichever the record supports. Be careful what goes into that total: whether psychotherapy minutes count toward E/M total time when no add-on is reported is not settled and payer policies differ, and a note describing psychotherapy while the E/M is leveled by time is a pattern some reviewers look at closely. Counting only E/M activities is the conservative approach.
Do I have to document start and stop times, or is a total enough?
A stated total is the minimum, and it should be a number, not a range and not "approximately 45 minutes." Start and stop times are stronger, and some payer policies ask for them. Since time is all that distinguishes these three codes, I write both.
Can I use these add-ons with an intake visit?
Not with 90791 or 90792. Those diagnostic evaluation codes are their own service and the add-ons do not attach to them. If your intake was billed as an E/M service instead, and you delivered separate and distinct psychotherapy in the same encounter, the add-on rules apply normally. See 90791 vs 90792 for how the intake codes differ.
What happens if a claim comes back denied?
Read the denial reason before rewriting anything. Add-on denials usually trace to a handful of causes: no E/M line on the claim, an incompatible primary code, a missing modifier 25 where the plan requires one even though the code set does not, frequency or utilization edits aimed at the longer tiers, a modifier or place of service problem on a telehealth claim, or a plan policy about who may report psychotherapy. Documentation quality drives the outcome of a review rather than an automated edit, and some plans run prepayment documentation review on the longer tiers.
Related guides
- Can you bill 99214 and 90833 together? Yes, and here is what each code has to prove
- CPT 90833 note example: an audit-ready E/M plus psychotherapy add-on note, annotated
- 90832 vs 90834 vs 90837: choosing and documenting the psychotherapy time codes
- 90785 interactive complexity: when the add-on applies and what the note has to show
- Psychiatric progress note example: an annotated medication management follow-up
OneStep Scribe is an AI scribe built for psychiatric prescribers. It listens to the visit, in person or over telehealth, and drafts the complete note from what occurred in the visit, including the telehealth details and a billing section, for your review and signature. Every account is NPI-verified.
Start a 14-day free trialThis article is educational and reflects one clinician's understanding of coding rules at the time of writing. It is not legal, billing, or payer-specific advice, and it does not guarantee reimbursement or audit outcomes. Coding rules, payer policies, and state and federal laws change; always verify current requirements with your payers, coding resources, and compliance advisors, and consult your licensing board(s), current DEA guidance, and a healthcare attorney for licensure, consent, and controlled-substance questions. CPT is a registered trademark of the American Medical Association.