Mental Health Billing Documentation by CPT Code
Each CPT code carries specific documentation requirements that must be met for insurance reimbursement. This resource provides detailed guidance for documenting each CPT code, showing how to structure your clinical notes to meet billing requirements while providing excellent client care.
Select a CPT code below and then choose your preferred note format (SOAP, DAP, BIRP, etc.) to see detailed documentation guidance specific to that combination.
CPT Codes
CPT 90791: Psychiatric Diagnostic Evaluation
Initial comprehensive psychiatric evaluation without medical services. Includes history, mental status examination, diagnostic formulation, and treatment planning. Typically 45-60 minutes. Establishes baseline for ongoing care and documents diagnostic impressions for medical record.
CPT 90792: Psychiatric Diagnostic Evaluation with Medical Services
Initial comprehensive psychiatric evaluation including medical services (physical exam, vital signs, labs if indicated). More extensive than 90791, includes medical assessment. Typically 60-90 minutes. Appropriate when medical evaluation is part of the initial assessment.
CPT 90832: Psychotherapy, 16-37 minutes
Individual psychotherapy for 16-37 minutes in duration. Can be used for follow-up sessions after initial diagnostic evaluation. Documentation must reflect therapeutic work and clinical content, not just counseling or supportive conversation.
CPT 90834: Psychotherapy, 38-52 minutes
Individual psychotherapy for 38-52 minutes. Most common length for weekly outpatient psychotherapy sessions. Requires documentation of clinical content, therapeutic focus, and measurable progress toward goals.
CPT 90837: Psychotherapy, 53+ minutes
Individual psychotherapy for 53 or more minutes. Extended sessions allowing for in-depth work, complex cases, or intensive processing. Requires robust clinical documentation justifying extended time.
CPT 90846: Family Psychotherapy without Patient
Family therapy session without the identified patient/client present. Appropriate for family sessions addressing family dynamics, caregiver stress, or systemic issues without the primary client. Time requirements and billing similar to individual therapy.
CPT 90847: Family Psychotherapy with Patient
Family therapy session with the identified patient/primary client present, addressing family dynamics, relationships, communication, and systemic issues. Often used for conjoint therapy, family sessions, or multi-person sessions involving the client.
CPT 90853: Group Psychotherapy
Psychotherapy provided to a group of individuals, typically 2 or more clients. Appropriate for support groups, process groups, skills-based groups, or therapeutic groups. Documentation requires noting group content, individual participation, and clinical work.
CPT 90839: Psychotherapy for Crisis, first 60 minutes
Extended psychotherapy session (up to 60 minutes) for a client in acute crisis, including risk assessment, stabilization, and intensive intervention. Requires documentation of crisis nature, risk evaluation, and intensive clinical work.
CPT 90840: Psychotherapy for Crisis, each additional 30 minutes
Additional 30-minute increments of crisis psychotherapy beyond the initial 60 minutes (code 90839). Used when crisis intervention extends beyond first hour. Each increment billed separately.
CPT 96130: Psychological Testing Evaluation, first hour
First hour of psychological testing including administration, scoring, and interpretation of standardized psychometric instruments. Requires specific assessment tools used and clinical integration of results with diagnostic formulation.
CPT 96131: Psychological Testing Evaluation, each additional hour
Each additional hour of psychological testing (after 96130) for extended test administration, scoring, interpretation, or report writing. Can include additional test instruments, complex scoring, or comprehensive report development.
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