90845 – Psychotherapy Service
CPT code 90845 represents a distinct mental or behavioral health service, including evaluation, therapy, or care coordination.
What is CPT
90845
?
90845 is a specific CPT code utilized in the realm of psychotherapy, particularly focused on individual therapy sessions. This code is essential for billing purposes within mental health services, and understanding its correct application is crucial for healthcare providers. In this entry, we will delve into the clinical purpose of CPT code 90845, outline documentation expectations, and discuss payer considerations to ensure compliance. Providers are encouraged to meticulously align their clinical notes with evidence-based interventions. It is vital to clearly document treatment goals, the interventions employed during the session, and measurable progress made by the patient. In instances where the code is time-based, precise recording of start and stop times is necessary to substantiate the duration billed and to comply with payer requirements.
Documentation Tips
When billing for time-based psychotherapy sessions using CPT code 90845, it is critical to document start and stop times accurately. This not only supports the billed duration but also aligns with payer expectations. In your clinical notes, include the therapeutic modality employed or the specific assessment instrument utilized during the session. Additionally, document the clinical focus of the session, the patient's response to the interventions, and a clear plan for follow-up care. For any scored instruments, retain copies of the completed tools in the patient’s record. If the session is conducted via telehealth, ensure that you document the patient’s consent and the platform used for the session. Utilizing a consistent SOAP (Subjective, Objective, Assessment, Plan) or DAP (Data, Assessment, Plan) structure in your notes will enhance audit readiness and compliance.
At a Glance
- Service Type: Psychotherapy
- Use Case: Individual Therapy
- Typical Setting: Outpatient clinic or telehealth (subject to payer policy)
- Billing Unit: Per session / per instrument (varies by specific code)
- Common Pairings: 90791, 96127, and various psychotherapy codes
Billing Examples
A clinician may conduct a therapy session focused on Cognitive Behavioral Therapy (CBT) to address a patient's panic disorder symptoms. During the session, the clinician would employ specific CBT techniques such as cognitive restructuring and exposure exercises. The clinician documents the interventions utilized, the patient’s emotional responses, and progress towards established treatment goals. If the session lasts for 45 minutes, the appropriate billing should reflect this duration with the correct time-based psychotherapy code. For instance, if the clinician decides to extend the session to 60 minutes to provide additional support, it is crucial to bill for the actual face-to-face time spent with the patient, adhering to the guidelines set for time-based coding.
Compliance Guidelines
- Always verify payer coverage and authorization requirements prior to billing for services rendered.
- Ensure that documentation supports medical necessity and that services are directly linked to appropriate ICD-10 diagnoses.
- Utilize correct modifiers, such as 95 for telehealth services, as mandated by payers.
- Avoid upcoding; select the code that accurately reflects the documented time and level of service provided.
- Conduct periodic audits of billing practices and documentation to identify areas for improvement and minimize claims denials.
Common ICD-10 Codes
Helpful links for mental health billing and documentation
- F32.0 - Major depressive disorder, single episode, mild
- F41.1 - Generalized anxiety disorder
- F33.1 - Major depressive disorder, recurrent, moderate
- F43.10 - Post-traumatic stress disorder, unspecified
- F41.9 - Anxiety disorder, unspecified
- F34.1 - Dysthymic disorder
Additional Resources
Helpful links for mental health billing and documentation
Related CPT Codes
Helpful links for mental health billing and documentation
Got questions? We’ve got answers.
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Q1: What is the primary purpose of CPT code 90845?
A: CPT code 90845 is designated for billing individual psychotherapy sessions where the clinical activities align with the code's definition. It is essential to ensure that documentation supports the billed services to avoid claims denials.
Q2: Is it permissible to bill this code for telehealth sessions?
A: Yes, many payers allow billing for telehealth services using CPT code 90845, provided that the service is synchronous and that appropriate modifiers and patient consent are documented. Always verify specific payer policies regarding telehealth coverage.
Q3: What type of documentation do payers typically request?
A: Payers commonly request documentation that includes the time spent during the session, the therapeutic techniques or assessment instruments utilized, the patient's responses, and a clear connection to a covered ICD-10 diagnosis.
Q4: Can CPT code 90845 be billed in conjunction with other services?
A: Yes, when billing for multiple services, it is crucial to document distinct times and the rationale for each service provided. Utilize add-on codes or adhere to Evaluation and Management (E/M) separation rules as applicable to ensure accurate billing.
Q5: What are some common reasons for claims denials related to this code?
A: Common denial reasons include missing or incomplete time records, insufficient documentation of medical necessity, incorrect use of modifiers, or billing beyond established frequency limits.
