90837

Psychotherapy, 60 minutes with patient and/or family member

Psychotherapy, an interactive mental health service, is provided for 60 minutes face-to-face with the patient and/or family member(s). This service is typically reported when the total duration of face-to-face time with the patient and/or family is 53 minutes or more. It involves the therapeutic exploration of various psychological issues, including behavior modification, supportive therapy, insight-oriented therapy, and cognitive-behavioral therapy techniques. This code is used when psychotherapy is the only service provided or when an E/M service is not separately reported by the same physician or other qualified healthcare professional on the same date. The purpose is to address mental health conditions, alleviate symptoms, improve functional abilities, and promote overall well-being through verbal and nonverbal communication and interventions.

Clinical Indications

  • Major Depressive Disorder (MDD)
  • Generalized Anxiety Disorder (GAD)
  • Panic Disorder
  • Post-Traumatic Stress Disorder (PTSD)
  • Obsessive-Compulsive Disorder (OCD)
  • Bipolar Disorder (as an adjunct to pharmacotherapy)
  • Eating Disorders (e.g., Anorexia Nervosa, Bulimia Nervosa, Binge-Eating Disorder)
  • Substance Use Disorders (as part of a comprehensive treatment plan)
  • Personality Disorders (e.g., Borderline Personality Disorder)
  • Adjustment Disorders with depressed mood, anxiety, or mixed features
  • Grief and bereavement reactions that are significantly impairing
  • Stress management and coping skill development for chronic medical conditions
  • Relationship and family problems causing significant psychological distress to the patient
  • Trauma-related symptoms and functional impairment

Procedure Steps

  1. Patient intake and initial assessment (for new patients) or re-assessment of current status (for established patients) to identify presenting problems, symptoms, and treatment goals.
  2. Establishment or review of the therapeutic alliance and treatment plan, including specific objectives for the session.
  3. Implementation of specific psychotherapeutic techniques relevant to the patient's diagnosis and treatment goals (e.g., cognitive restructuring, behavioral experiments, exposure therapy, psychodynamic interpretation, emotional regulation skills training, interpersonal skill building).
  4. Facilitation of patient insight into thoughts, feelings, and behaviors, and exploration of underlying conflicts or patterns.
  5. Development and reinforcement of coping strategies, problem-solving skills, and adaptive behaviors.
  6. Monitoring of patient's emotional state, progress toward goals, and response to interventions.
  7. Discussion of homework assignments or between-session practices to consolidate learning and promote generalization.
  8. Summary of the session, including key insights, agreements, and plans for future sessions.
  9. Thorough documentation of the session, including the specific interventions, time spent, patient's response, and any modifications to the treatment plan.

Coding Guidelines

  • CPT code 90837 represents 60 minutes of psychotherapy when performed for 53 minutes or more of face-to-face time with the patient and/or family.
  • This code should be reported for standalone psychotherapy services. If an Evaluation and Management (E/M) service is also provided by the same physician or other qualified healthcare professional on the same day, an add-on psychotherapy code (e.g., 90838 for 53+ minutes) should be used in conjunction with the appropriate E/M code, not 90837.
  • Documentation in the medical record must clearly support the medical necessity of the psychotherapy, detailing the presenting problems, goals, specific interventions used, patient's response, and the total face-to-face time spent.
  • Family members may be present during the session if their participation is integral to the patient's treatment and documented as such.
  • This service may be provided in various settings including office, hospital, or via telehealth, adhering to specific payer regulations for telehealth services.
  • Only one psychotherapy service may be reported per patient per day by the same provider.
  • Providers must be appropriately licensed and qualified to provide psychotherapy services (e.g., psychiatrists, psychologists, licensed clinical social workers, licensed professional counselors).

Associated ICD-10 Codes