June 2010
Reporting psychotherapy code CPT 90808
According to Current Procedural Terminology (CPT®) coding guidelines, CPT 90808 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 75 to 80 minutes face-to-face with the patient is only appropriate to report in exceptional circumstances, not for routine care. Situations requiring an extended visit of this level should be fully documented in the clinical record.
The following examples illustrate encounters that may warrant extended sessions:
- Temporary need as patient transitions to less frequent therapy sessions
- For patients seen less frequently than weekly due to geographic or transportation limitations
- Following an acute trauma, necessary to explore the incident and provide emotional stabilization
- An unexpected crisis situation arising from a regularly scheduled session (e.g., patient threatening suicide or homicide) requiring extended time to stabilize the patient, involving family members or arranging for emergency care
Extended individual psychotherapy sessions solely for the preference or convenience of the patient or mental health professional are not considered medically necessary. Clinical records may periodically be requested to document the necessity for extended sessions.