For a child diagnosed with adjustment disorder with mixed disturbance, should I bill both CPT 99214 (established patient office visit) and CPT 90833 (psychotherapy add‑on)?

Billing for Adjustment Disorder with Mixed Disturbance in Children

Yes, you can bill both CPT 99214 and CPT 90833 together when you provide both an evaluation/management service and psychotherapy during the same visit for a child with adjustment disorder with mixed disturbance.

Understanding the Billing Structure

The key to proper billing lies in understanding that these are distinct but complementary services:

• CPT 99214 represents the established patient office visit that includes medical evaluation and management (E/M). According to AAP guidelines, this code is appropriate for evaluations that are "detailed and moderately complex or take at least 25 min (with more than half spent counseling)" 1.

• CPT 90833 is a psychotherapy add-on code that represents 16-37 minutes of psychotherapy provided in addition to the E/M service during the same encounter.

When This Combination Is Appropriate

You should bill both codes when:

• You perform a medical evaluation addressing the child's adjustment disorder (assessing symptoms, reviewing medications, evaluating medical decision-making needs)
• AND you provide distinct psychotherapy services during the same visit (therapeutic interventions, coping strategies, behavioral techniques)
• The psychotherapy component lasts 16-37 minutes
• More than half of the total visit time is spent in counseling/coordination of care if using time-based billing for the 99214

Critical Documentation Requirements

To support billing both codes, your documentation must clearly demonstrate:

1. Separate components: The medical E/M work (symptom assessment, treatment planning, medication management considerations) distinct from the psychotherapy work (therapeutic interventions, cognitive-behavioral techniques)

2. Time documentation: If billing 99214 based on time, document that >50% of at least 25 minutes was spent counseling. For 90833, document 16-37 minutes of psychotherapy

3. Medical necessity: The adjustment disorder diagnosis justifies both the medical evaluation and psychotherapy intervention

Important Caveats and Pitfalls

Provider type matters: If you are a clinical psychologist or clinical social worker, you cannot bill CPT 90833 under Medicare rules, as these practitioners are specifically prohibited from billing psychotherapy codes that include medical E/M services (CPT codes 90792,90833,90836, and 90838) 2. However, physicians, physician assistants, nurse practitioners, clinical nurse specialists, and nurse-midwives can bill these codes 2.

Modifier requirements: When billing via telemedicine, append modifier "95" to indicate services were provided using real-time interactive audio-video telecommunications 3. The standard in-person visit does not require special modifiers for this code combination.

Payer-specific rules: While Medicare has specific restrictions, private insurance and Medicaid may have different policies. Verify coverage with individual carriers, as approximately 35 states plus DC have telemedicine parity laws, though these mandate coverage parity, not necessarily payment parity 3.

Practical Billing Algorithm

Step 1: Determine if you provided both medical E/M and psychotherapy

• If only psychotherapy → Bill standalone psychotherapy code (90832,90834, or 90837)
• If only medical evaluation → Bill appropriate E/M code only (99214 or 99215)
• If both → Proceed to Step 2

Step 2: Verify your provider credentials

• Physician, PA, NP, CNS, or nurse-midwife → Can bill both codes
• Clinical psychologist or clinical social worker → Cannot bill 90833; use standalone psychotherapy codes instead

Step 3: Document appropriately

• Clearly separate medical E/M documentation from psychotherapy notes
• Record time spent on each component
• Justify medical necessity for both services

Step 4: Bill with appropriate codes

• Primary code: 99214 (or 99215 if more complex/longer)
• Add-on code: 90833
• Add modifier 95 if provided via telemedicine

This billing approach is supported by established coding guidelines and reflects the reality that children with adjustment disorders often require both medical oversight and therapeutic intervention during the same clinical encounter 1, 3.