What makes a psychiatry superbill different
Most mental health superbills list one code per visit. Psychiatry visits often need two: an evaluation and management (E/M) code for the medical work, such as reviewing symptoms and side effects, adjusting medication or ordering labs, plus a psychotherapy add-on when you also provide therapy in the same visit. Insurers reviewing an out-of-network psychiatry claim expect to see both lines with the same date, each pointing to the diagnoses it supports.
The rest of the superbill is standard: practice and prescriber details with an individual NPI and Tax ID, the patient’s insurance information, ICD-10-CM diagnoses, and one line per service with a place of service, units and fee.
Psychiatry CPT codes at a glance
| Code | When to use it |
|---|---|
| 90792 | Initial psychiatric evaluation that includes medical services, such as a medication history, relevant physical exam elements or prescribing |
| 90791 | Diagnostic evaluation without medical services |
| 99202-99205 | New patient visit, leveled by decision making (straightforward, low, moderate, high) or by total time on the date |
| 99212-99215 | Established patient follow-up, such as medication management, leveled the same way |
| 90833 / 90836 / 90838 | Psychotherapy added to an E/M visit: 16-37, 38-52 or 53+ minutes of therapy |
| 90834 | A psychotherapy-only visit with no E/M component |
| 90785 | Add-on for interactive complexity, attached to the psychotherapy or evaluation |
| 96127 | A scored screener, such as a depression or anxiety scale, one unit per instrument |
When an E/M code is chosen by time, current CPT minimums are 15, 30, 45 and 60 minutes for 99202 to 99205, and 10, 20, 30 and 40 minutes for 99212 to 99215, counting all of your time on that date.
Pairing E/M visits with psychotherapy add-ons
The add-on codes only work when both services are real and distinct. A few principles keep the pair defensible:
- Separate the time. Minutes spent on psychotherapy cannot also count toward the E/M visit. For this reason, many psychiatrists level the E/M by medical decision making whenever they bill an add-on.
- Document both parts. The note should show the medical work (symptom review, medication decisions, risks) and the psychotherapy (the technique used, the patient’s response and the time).
- Use the add-on, not the standalone code. With an E/M visit, therapy goes on 90833, 90836 or 90838. 90832, 90834 and 90837 are only for visits with no E/M component.
- One evaluation per day. 90791 and 90792 are not reported with an E/M code for the same patient on the same date.
In the sample, the follow-up visit 14 days ago is billed as 99214 for moderate-complexity medication management plus 90833 for about 25 minutes of supportive psychotherapy. The telehealth follow-up today is a 99213 with no add-on.
MDs, DOs, PMHNPs and PAs
The sample uses an MD, but the template is the same for any prescriber in psychiatry. Psychiatric-mental health nurse practitioners and physician assistants bill the same evaluation, E/M and add-on codes; just put your own credentials and license number in the provider fields. Some plans process claims from nurse practitioners differently, and a few have specific rules for PAs, so patients should check how their plan handles out-of-network claims from your license type.
Telehealth and modifiers
For video visits, many plans want POS 10 when the patient is at home and POS 02 when they are elsewhere, and some commercial plans prefer POS 11 with modifier 95. Audio-only follow-ups are accepted by some plans with modifier 93. Our guide to telehealth place of service codes covers the options. Modifier 25 is for a significant, separately identifiable E/M visit on the same day as a procedure; it is not normally needed for the psychotherapy add-ons. Prescribing controlled substances by telehealth has its own federal and state rules that are separate from billing.
Psychiatry-specific gotchas
- Medicare opt-out. If you have opted out of Medicare and see patients under private contracts, those patients cannot submit your superbill to Medicare for reimbursement.
- New versus established. A patient is new if they have not received professional services from you, or from a colleague of the same specialty in your group, within the past three years.
- Labs and medications are separate. Lab tests you order are billed by the lab, and prescriptions go through the pharmacy benefit. Neither belongs on your superbill.
- HSA and FSA. Many patients pay psychiatry fees from tax-advantaged accounts. Our HSA and FSA superbill guide explains what administrators look for.
How to fill this psychiatry superbill template
- Prescriber details. Enter the practice name, your name and credentials (MD, DO, PMHNP-BC, PA-C), license number, address, phone, email, individual NPI and Tax ID. The NPI field validates the check digit.
- Patient details. Add the patient’s name, date of birth, address, insurance carrier, member ID and group number.
- Diagnoses. Add up to 12 ICD-10 codes, lettered A to L, with the main reason for the visit first.
- Visit lines. For each date, add the evaluation or E/M line first, then the add-on line if you provided psychotherapy. Both lines share the date and place of service.
- Pointers, units and fees. Point each line to its diagnoses, leave units at 1, and enter your fee for each code.
- Finish. Enter the amount paid, type your signature, check the list of missing fields, then Print / Save as PDF.
Create your psychiatry superbill
Load the sample to see a finished psychiatry superbill, then replace it with your own practice and patient details in the generator above; nothing is uploaded. For background, read the CPT 90791 guide, which also compares it with 90792, and our explanation of superbills versus the CMS-1500 claim form. If you work alongside testing psychologists, point them to the psychologist template.