🧠 Mental Health Coding Guidelines

Mental health coding involves using the correct CPT® (procedure) and ICD-10-CM (diagnosis) codes to report psychiatric, psychological, and counseling services.

Accurate coding ensures proper reimbursement, maintains legal compliance, and reflects the true nature of care provided to patients with mental or behavioral health needs.

🧩 1. Code Sets Used in Mental Health

Code Set Purpose

CPT (Current Procedural Terminology) Describes the service or procedure provided (e.g., therapy session, psychiatric evaluation).

ICD-10-CM (Diagnosis Codes) Describes the patient’s mental health condition or disorder.

HCPCS (when used) Reports some medications, telehealth modifiers, or other services not listed in CPT.

⚕️ 2. Common CPT Codes in Mental Health

🩺 Psychiatric Diagnostic Evaluation

CPT Code Description

90791 Psychiatric diagnostic evaluation (no medical services, typically used by psychologists, therapists, counselors).

90792 Psychiatric diagnostic evaluation with medical services (used by psychiatrists or nurse practitioners).

💬 Psychotherapy (Therapy Sessions)

CPT Code Description

90832 Psychotherapy, 30 minutes (individual).

90834 Psychotherapy, 45 minutes (individual).

90837 Psychotherapy, 60 minutes (individual).

90846 Family therapy (without the patient present).

90847 Family therapy (with the patient present).

90853 Group psychotherapy (other than a multiple-family group).

🕒 Tip:

The times listed are approximate. The session must meet at least 16 minutes to bill for 30 minutes (90832), and so on.

💊 Medication Management

CPT Code Description

90863 Pharmacologic management (add-on to therapy codes).

99212–99215 Evaluation and management (E/M) office visits for established patients — used when prescribing or adjusting medications.

🌐 Telehealth Services

During or after the COVID-19 pandemic, telehealth became common for behavioral health.

Use the same CPT codes, but add a telehealth modifier (e.g., 95) and use Place of Service (POS) 02 or 10 depending on payer requirements.

Example:

90837-95 — Psychotherapy, 60 minutes via telehealth.

🧠 3. Common ICD-10-CM Diagnosis Codes

Condition ICD-10-CM Code Description

Major depressive disorder, single episode, mild F32.0 Single episode of mild depression

Generalized anxiety disorder F41.1 Persistent, excessive worry and anxiety

Bipolar I disorder, current episode manic F31.10 Bipolar disorder with mania

PTSD (Post-traumatic stress disorder) F43.10 PTSD, unspecified

ADHD, combined type F90.2 Attention deficit hyperactivity disorder

Adjustment disorder with depressed mood F43.21 Reaction to stress with sadness or depression

Schizophrenia, unspecified F20.9 General diagnosis for schizophrenia

🩹 Tip: Always code the primary mental health diagnosis first, followed by any secondary or comorbid conditions.

🧾 4. Documentation Requirements

Proper documentation supports your codes and ensures compliance with payer rules.

Include the following:

✅ Patient identifying information

✅ Reason for visit / presenting problem

✅ Diagnosis (DSM-5 and ICD-10 alignment)

✅ Treatment plan and goals

✅ Type of therapy and duration (minutes)

✅ Progress notes

✅ Provider signature and credentials

⚙️ 5. Modifiers Commonly Used in Mental Health Coding

Modifier Description Example Use

-25 Significant, separately identifiable E/M service on the same day as psychotherapy When therapy and medication management occur in one session

-59 Distinct procedural service When two different services are performed

-95 Telehealth service (synchronous) Used for telemedicine sessions

-GT Telehealth (older modifier, used by some payers) Used for certain insurance carriers

💡 6. Time-Based Coding Guidelines

Psychotherapy codes are time-based.

You must spend at least 16 minutes for a 30-minute code (90832).

Document start and end times in your notes.

Example:

“Individual psychotherapy session, 2:00–2:50 PM (50 minutes), focused on coping strategies for anxiety.”

🧩 7. Tips for Accurate Mental Health Coding

✅ Always match CPT and ICD-10 codes appropriately (e.g., therapy for depression → F32.0 + 90834).

✅ Include medical necessity in documentation (why the service was required).

✅ Know payer-specific rules for telehealth or time-based billing.

✅ Use the correct provider type — psychiatrists, psychologists, social workers, and counselors may have different billing rules.

✅ Never “upcode” (bill longer sessions than documented).

⚠️ 8. Common Coding Mistakes

❌ Using time-based therapy codes without documentation of time

❌ Billing medication management and psychotherapy without modifier -25

❌ Missing or vague diagnosis (e.g., “depression” without specifying type/severity)

❌ Failing to document telehealth requirements (location, consent, technology used)

🏁 Summary

Category Examples

Evaluation Codes 90791, 90792

Psychotherapy Codes 90832, 90834, 90837

Family/Group Therapy 90846, 90847, 90853

Medication Management 90863, 99212–99215

Telehealth Modifiers -95, -GT

Common Diagnoses F32.0 (Depression), F41.1 (Anxiety), F43.10 (PTSD)

🧘‍♀️ Final Thought

Mental health coding requires precision and compliance. Always align:

The CPT code (what you did)

The ICD-10 code (why you did it)

And the documentation (proof you did it)

Proper coding ensures both ethical billing and quality patient care.

Learn Medical Coding Course in Hyderabad

Read More

OB/GYN Coding: What You Need to Know

How to Code for Telehealth Visits

Common Errors in Dermatology Coding

🔍 Specialty in Medical Coding

Visit Our Quality Thought Institute

Get Directions

November 05, 2025

Subscribe by Email

Follow Updates Articles from This Blog via Email