How to bill insurance for extended therapy sessions

There has been a great deal of confusion about billing for psychotherapy sessions that last longer than 60 minutes.

How should they be coded?

Will health insurance plans cover these longer sessions?

Must the therapist get preauthorization?

Should the therapist document these sessions differently?

This article will address these questions, review the billing codes that have been used for these codes, and bring you up to date on the latest billing options.

What are CPT billing codes?

CPT codes are the 5-digit codes used on health insurance claim forms and superbills (also called statements) to identify the types of services rendered by the medical professionals, including mental health clinicians.

The American Medical Association (AMA) maintains these codes and updates them regularly.

The history of CPT codes for longer sessions

Prior to 2012, there was a special CPT code for longer sessions. That code, 90808, was used for sessions 75 – 80 minutes long.

However, in 2013, when the AMA did a major revision of the CPT codes, the 90808 code was deleted.

The AMA then offered only three timed codes for individual psychotherapy, where the longest one was 90837 (see table below).

The 90837 code was defined as a 60-minute psychotherapy code, but could be used for sessions with a time range of 53 minutes and above.

90832	30-minute psychotherapy (16 – 37 minutes)
90834	45-minute psychotherapy (38 – 52 minutes)
90837	60-minute psychotherapy (53 minutes and above)

 

Since 90837 was to be used for any session over 53 minutes, there was no way to distinguish a 60-minute session from a longer session.

Because there was no unique billing code for sessions longer than 60 minutes, insurance reimbursement for a longer session (ex a 90- or 120-minute session) would be the same as the 60-minute rate.

Then in 2016, the AMA allowed Prolonged Services codes 99354 and 99355 to be used by non-medical personnel.

These “add-on codes” could be added to a CPT 90837 for individual sessions 90 minutes and more. In 2017, the AMA allowed these codes to be added to family or couples therapy CPT code 90847 sessions that lasted 80 minutes or more.

While some health plans never covered Prolonged Services codes, many did.

Therefore, for a few years some therapists and clients enjoyed a significant increase in reimbursement for longer sessions.

Then, on January 1, 2023, codes 99354 and 99355 were deleted from the CPT code set. The code 99417 was deemed to be the replacement code for 99354 and 99355.

However, coding experts seem to agree that this code cannot be used in conjunction with psychotherapy codes 90837 or 90847.  And no other obvious options were offered.

So, what billing options are left for billing extended sessions?  

As of this writing, there is no CPT code for a psychotherapy session longer than 60 minutes other than 90837, and for this code you will be paid the same rate as you would for a 60-minute session.

Therefore, it is wise to question the health plan to find out what their 90837 reimbursement policy, and verify if preauthorization is needed.

Will health plans cover routine 90837s for a client?

While some health plans have no issue with 90837 being used regularly for all your sessions, many plans feel that a 45-minute session should be sufficient for routine therapy.

These plans view the 90837 53-minute or longer session as necessary only for complex cases, dual diagnoses, or specialized modalities that take additional session time.

These modalities might include EMDR, systematic desensitization, specialized trauma treatments, and DBT protocols.

In fact, up until 2018 United Health/OPTUM required preauthorization for use of the 90837 code.

While preauthorization is no longer needed by this health plan for 90837, even now in a records audit, some health plans like Medicare, Blue Cross, and United/OPTUM might not reimburse for a 90837 if you are unable to adequately explain the need for the longer session.

For a 90-minute session, you might ask the health plan if it is possible to bill for two units of 90834, or for a 120-minute session, two units of 90837.

For an extended couples or family session you might check if you can bill for two units of 90847 (this seems less accepted). Some therapists have reported that they were reimbursed when they billed 2 units.

The risk is that the health plan could deny payment for the entire session instead of just paying one unit.

And, even if the health plan pays, billing for two units on one day could increase your risk of an audit.

When reading your notes, the health plan may decide they should NOT have paid for the extra time, and may request money back.

If you are a network provider, can you bill one 45- or 60-minute session to insurance, and contract privately with the client to pay any additional time out of pocket?

As always, it’s best to check your health plan contract to see if there is anything that might forbid this.

A client should retain the right to pay for any services that are not covered by their plan.

However, it is a gray area, and if you are audited, the health plan may say you violated your contract by charging the client more than their copayment and deductible for a covered session.

But, is this extra time part of the covered session?

One insurance network executive told me billing clients for the extra time would be allowed as long as the client signed a Private Pay Agreement in advance stating he understands that this additional time would be his responsibility, and he understood how much he would owe for the sessions.

If the session meets the criteria for a crisis session, the choice might be made to bill using the crisis CPT code: 90839 for the first 60 minutes of a crisis session, 90840 as the add-on for each 30 minutes of additional time after the 60 minute.

Note that  90840 is an add-on code that can only be used with 90839, and 90839 cannot be used with any other psychotherapy code.

In order for the crisis codes to apply, the presenting problem must require immediate attention to a client in high distress, including life-threatening or at least highly complex crisis clinical situations.

Can you use 90837 for ongoing couples or family therapy?

One of the biggest mistakes clinicians make with the 90837 CPT code is using this code for couples or family therapy. Often this is done when 90837 pays more than the couples/family code 90847.

But, you must use 90847 for ongoing couples or family therapy sessions if the client is present, and 90846 if the client is not present.

Both of these codes are 50 minutes, with a time range of 26 minutes and above.

Using the 90837 for couples or family therapy can lead to having to pay money back to a health plan if it is discovered that the sessions were not individual therapy.

Must you document longer 90837 sessions differently?

Since longer sessions are more vulnerable to health plan scrutiny and audit, It is essential to document in every session note why the longer session was clinically necessary.

The rationale must be deemed medically necessary and related to the client’s needs and not just their convenience or desire.

For example, a trauma-related treatment modality such as EMDR may require a prolonged service time.

A few final words

The absence of an extended session CPT code has led many therapists who do longer sessions to resign from insurance networks.

Many therapists feel they are unable to be adequately reimbursed for the extra time they are putting in, which may be essential to the type of treatment they provide.

While we can look for different ways to code and bill for these longer sessions, and hope that new codes emerge for longer sessions, it must be acknowledged that our discussions are the result of an industry-wide trend toward encouraging briefer treatment, and disincentivizing longer therapy sessions.

How SimplePractice streamlines running your practice 

SimplePractice is HIPAA-compliant practice management software with booking, billing, and everything you need built into the platform.

If you’ve been considering switching to an EHR, SimplePractice empowers you to run a fully paperless practice—so you get more time for the things that matter most to you.

Try SimplePractice free for 30 days. No credit card required.