90836

Psychotherapy, 45 minutes with patient and/or family member when performed with an evaluation and management service

CPT code 90836 represents psychotherapy services lasting 38-52 minutes of face-to-face time with a patient and/or family member, provided in conjunction with a separately identifiable Evaluation and Management (E/M) service on the same calendar date. This service focuses on the interactive, therapeutic process to address mental health conditions, behavioral issues, or emotional disturbances through various psychotherapeutic techniques. It involves the use of verbal and non-verbal communication to facilitate insight, develop coping mechanisms, and promote behavioral change. The time spent on psychotherapy must be distinct and documented separately from the time spent on the E/M service.

Clinical Indications

  • Major Depressive Disorder
  • Generalized Anxiety Disorder
  • Panic Disorder
  • Post-Traumatic Stress Disorder (PTSD)
  • Adjustment Disorders with depressed mood, anxiety, or mixed features
  • Obsessive-Compulsive Disorder (OCD)
  • Bipolar and Related Disorders (e.g., Bipolar I, Bipolar II)
  • Eating Disorders (e.g., Anorexia Nervosa, Bulimia Nervosa, Binge-Eating Disorder)
  • Personality Disorders (e.g., Borderline Personality Disorder)
  • Substance-Related and Addictive Disorders (when addressing co-occurring mental health issues)
  • Grief and bereavement counseling for significant mental health impact
  • Stress management and coping skills development for chronic medical conditions with psychological overlay
  • Familial or relational problems significantly impacting individual mental health

Procedure Steps

  1. Establish and maintain a therapeutic alliance and rapport with the patient and/or family.
  2. Perform a focused assessment of the patient's current mental status, symptoms, stressors, and functional impairments, distinguishing from the E/M assessment.
  3. Collaboratively identify and define specific therapeutic goals for the session and overall treatment plan.
  4. Employ evidence-based psychotherapeutic techniques (e.g., cognitive-behavioral therapy (CBT), psychodynamic therapy, supportive therapy, dialectical behavior therapy (DBT) skills) tailored to the patient's diagnosis and needs.
  5. Facilitate insight into thoughts, feelings, and behaviors; explore past experiences, interpersonal dynamics, and coping strategies.
  6. Teach and reinforce coping skills, problem-solving strategies, and communication techniques.
  7. Address resistance, transferences, and other therapeutic process issues as they arise.
  8. Engage family members, if present, to understand and modify interaction patterns that impact the patient's mental health.
  9. Monitor the patient's progress, response to interventions, and adjust the treatment plan accordingly.
  10. Provide psychoeducation regarding the patient's condition and treatment options.
  11. Document the specific content of the psychotherapy session, therapeutic interventions used, time spent, and patient's response, clearly distinct from the E/M service.

Coding Guidelines

  • CPT code 90836 is an add-on code and must be reported in conjunction with an appropriate Evaluation and Management (E/M) service (e.g., 99202-99215, 99241-99245, 99341-99350) on the same date of service.
  • This code represents psychotherapy services lasting 38-52 minutes of face-to-face time. For psychotherapy lasting 16-37 minutes, use 90833. For psychotherapy lasting 53 minutes or more, use 90838.
  • The psychotherapy time must be clearly documented and distinctly separate from the time spent on the E/M service. The E/M service must be medically necessary and separately identifiable.
  • Both the psychotherapy service and the E/M service require separate medical necessity documentation supporting each component.
  • Do not report 90836 if the psychotherapy service does not meet the minimum time threshold of 38 minutes, or if it exceeds 52 minutes.
  • This code should not be reported with other psychotherapy codes for the same encounter (e.g., 90832, 90834, 90837, 90839, 90847).
  • Interactive complexity (90785) may be reported with 90836 if specific criteria for interactive complexity are met and documented.
  • Services must be performed by a physician or other qualified healthcare professional (QHP) legally authorized to provide psychotherapy.

Associated ICD-10 Codes