E&M Codes With Psychotherapy Add-Ons: The Billing Rules Clinics Keep Getting Wrong

Introduction

E&M codes combined with psychotherapy add-on codes (90833, 90836, 90838) generate higher reimbursement — but only if the provider meets strict payer requirements. Most denials occur because clinics misunderstand time rules, documentation standards, or when combinations are allowed.

Here’s a clear, compliance-ready breakdown.

1. Add-On Psychotherapy Codes Can Only Be Billed With E&M Codes

Psychotherapy add-on codes cannot be billed alone — they must be paired with an appropriate E&M code.

Correct combinations:

• 99213 + 90833 (30-minute add-on psychotherapy)

• 99214 + 90836 (45-minute add-on psychotherapy)

• 99215 + 90838 (60-minute add-on psychotherapy)

Incorrect:

• 90833 alone

• 90836 alone

• 90838 alone

These codes represent psychotherapy performed in addition to medical management, not as a standalone service.

2. Documentation Must Support BOTH Services Separately

You need two components clearly documented in the note:

A. Medical Management (E&M) Documentation

• Medication review

• Treatment decision-making

• Mental status exam

• Risk assessment

• Updates to treatment plan

B. Psychotherapy Documentation

• Time spent (must be precise)

• Treatment modality (CBT, DBT, trauma-focused, etc.)

• Themes discussed

• Progress toward goals

If documentation blends both services together, payers downcode or deny the claim.

3. Time Requirements Are Non-Negotiable

Psychotherapy time must meet minimum thresholds:

Important:
This psychotherapy time must be in addition to the medical evaluation portion.

4. Do NOT Combine E&M + Psychotherapy If…

You cannot bill the combination if:

• The visit is medication management only

• The psychotherapy time is below the minimum threshold

• A trainee/postdoc performed the psychotherapy but is not eligible for E&M billing

• The note does not show two distinct services

• The medical portion is “minimal” or missing clinical decision-making

Payers audit these combinations aggressively — sloppy documentation is a red flag.

5. Modifier 25 Is Usually Required

Most insurers require Modifier 25 on the E&M code to show that:

• The E&M service was significant and separately identifiable, not part of psychotherapy

• Both services were medically necessary

• Documentation supports the separation

Example:

• 99214-25 + 90836

Check plan-specific rules (UHC, BCBS, Medicare, Medicaid) because some carve-outs differ.

Conclusion

E&M + psychotherapy combinations are highly profitable, but only if compliant.
Clinics that follow time requirements, documentation structure, and correct modifier usage consistently experience clean claims, stronger reimbursement, and fewer audits.