What is the current guidance for reporting E/M services with psychotherapy codes 90833 , 90836 , and 90838 ? Per CPT coding conventions, time is not an allowable component for E/M code selection in this situation because psychotherapy services are time-based codes. Both services cannot be assigned based on time. However, the psychotherapy subsection guidelines do not reflect the 2021 changes to the criteria for E/M office visit code selection (medical decision making [MDM] or time). If health care professionals follow the 2021 guidelines for level selection for E/M services, they must use MDM to assign the E/M level of service. If they are allowed to follow the CMS 1995/1997 Documentation Guidelines for Evaluation and Management Services, they may use history, examination, and MDM. What is the correct criterion to use for E/M code selection? ...

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Note:  The following article synopsis was NOT provided by the AMA. It was created by Find-A-Code/innoviHealth.

Article Overview

This article explains current CPT guidance for reporting evaluation and management services alongside psychotherapy add-on services. It is aimed at coders, billers, compliance staff, and clinicians who need to understand the general criteria discussed for E/M level selection, the relationship to psychotherapy time-based services, and the role of recent CPT editorial review and forthcoming code set updates.

Why This Topic Matters

Correctly pairing E/M services with psychotherapy add-on codes affects compliant reporting, documentation alignment, and code selection under current CPT conventions. The article is relevant for teams that need to stay current with CPT editorial changes and evolving guidance for office and outpatient E/M reporting.

Codes Discussed

• CPT: 90833
• CPT: 90836
• CPT: 90838

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