CPT® code 90838 is used to bill 60-minute psychotherapy sessions conducted with an evaluation and management (E/M) component. This code represents a session where a physician or other qualified mental health provider delivers both talk therapy and medical assessment/intervention, typically for an established patient.
Key facts about CPT® Code 90838
- Service type: Psychotherapy with E/M
- Session length: 60 minutes
- Setting: Outpatient, office-based or telehealth
- Providers: Psychiatrists, psychiatric nurse practitioners, or other licensed prescribers who can deliver both therapy and medical management
- Typical use case: A psychiatric follow-up visit where the provider assesses medication needs, adjusts treatment plans, and provides in-depth psychotherapy.
CPT® Code 90838 components
To report 90838, a provider must:
- Provide a full E/M service (e.g., medication evaluation, risk assessment, treatment planning)
- Deliver at least 60 minutes of psychotherapy
- Document both components clearly in the chart: medical decision-making or time for E/M, and therapy details (e.g., modality, patient response, duration)
The psychotherapy portion may involve techniques such as CBT, psychodynamic therapy, or supportive counseling. The E/M portion may include assessment of symptoms, adjustment of psychotropic medication, coordination with other care providers, or addressing medical comorbidities.
90838 is often used when treating:
- Major depressive disorder with comorbid medical conditions
- Bipolar disorder requiring medication management and therapy
- PTSD where trauma-focused therapy is paired with pharmacologic support
- Complex anxiety disorders requiring integrated care
- Chronic pain or insomnia being addressed through psychopharmacology and behavioral strategies
Payer guidelines and documentation tips
Insurers typically require that the psychotherapy and E/M portions are both medically necessary and clearly distinguished in documentation. Providers should:
- Specify total time spent and break out minutes for E/M and therapy if possible
- Link interventions to active diagnoses
- Justify medication changes or continuation with clinical rationale
- Note patient response and therapeutic progress
Telehealth and CPT® 90838
CPT® 90838 is approved for telehealth by many payers, especially when video is used. During the COVID-19 PHE and in its aftermath, many states and private insurers permanently adopted telehealth parity for mental health services. Always verify payer-specific guidelines.
How OptiMantra supports billing for 90838
For integrative and psychiatric providers, OptiMantra’s EMR makes it easy to document, code, and bill for CPT® 90838. The platform:
- Supports dual documentation for psychotherapy and E/M
- Allows time tracking to meet compliance needs
- Integrates diagnosis, medications, and therapy notes in a single workflow
- Enables telehealth appointments with compliant documentation fields
- Automates coding prompts based on visit content
Whether you're a solo psychiatric NP or part of a collaborative wellness team, OptiMantra helps ensure your CPT 90838 encounters are fully documented, easy to bill, and seamlessly integrated into your patient care model.
Try OptiMantra for free here!
