CPT® Code 90887 is used to report the interpretation or explanation of the results of psychiatric or other medical examinations, procedures, or accumulated clinical data to a family member or other responsible person. The service is provided without the patient present when discussing the findings is clinically appropriate and supports the patient's care.
This code is intended for situations in which communicating examination results and treatment implications to family members or caregivers is medically necessary to facilitate patient management.
Key Facts About CPT® 90887
- Service type: Psychiatric service
- Service: Interpretation and explanation of examination or procedure results
- Recipient: Family member or other responsible person
- Patient presence: Patient is typically not present
- Provider type: Psychiatrists, psychologists, physicians, and other qualified healthcare professionals
Common clinical indications:
- Discussion of psychiatric evaluation findings with caregivers
- Explanation of neuropsychological or psychological testing results
- Review of treatment recommendations with family members
- Counseling caregivers regarding diagnosis, prognosis, or care planning
- Coordination of care for patients who require caregiver involvement
When to Use CPT® 90887
CPT 90887 is appropriate when:
- Interpreting or explaining psychiatric or medical examination results to a family member or responsible person
- The discussion is medically necessary and contributes to the patient's treatment or care planning
- The patient is not present during the encounter
- The service is distinct from psychotherapy or family psychotherapy services
Examples:
- Reviewing psychiatric evaluation results with the parent of a minor patient
- Explaining neuropsychological testing findings to a patient's caregiver
- Discussing a diagnosis and treatment recommendations with a legal guardian
- Meeting with family members to explain the clinical significance of examination results and next steps in care
Documentation Requirements
To support CPT 90887 billing, documentation should include:
- Patient identifiers and date of service
- Identity and relationship of the family member or responsible person
- Clinical reason for the discussion
- Summary of the examination or procedure results reviewed
- Interpretation and recommendations provided
- Medical necessity for communicating with the family member or caregiver
- Provider signature and credentials
Documentation should clearly demonstrate how the discussion supports the patient's ongoing care.
Reimbursement and Coding Considerations
- CPT 90887 is reported for the interpretation or explanation of examination results, not psychotherapy services
- The service is generally provided without the patient present
- Diagnosis coding should support the patient's underlying psychiatric or medical condition
- Coverage varies by payer, and some insurers may have specific policies regarding family consultation services
- Documentation should clearly establish medical necessity and distinguish the service from other counseling or care coordination activities
Always verify payer-specific behavioral health billing requirements before submitting claims.
How OptiMantra Supports Behavioral Health Documentation
OptiMantra’s integrated EMR and practice management system streamlines documentation and billing for CPT 90887:
With OptiMantra, providers can:
- Document family and caregiver consultations within the patient chart
- Record examination results, clinical recommendations, and care plans
- Link discussions to diagnoses, treatment goals, and follow-up services
- Maintain organized behavioral health documentation that supports billing compliance and audit preparedness
- Coordinate communication among providers, patients, and caregivers
- Track ongoing behavioral health care within a centralized patient record
By centralizing behavioral health documentation and care coordination, OptiMantra helps practices improve efficiency, ensure compliance, and support high-quality patient care.
Try OptiMantra for free here!
Disclaimer: CPT® codes are maintained by the American Medical Association. This guide is for informational purposes only and does not replace official coding guidelines or payer policies.
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