Is it appropriate to bill CPT code 90836 (psychotherapy, 45 minutes) and CPT code 99213 (office visit for brief medication review) together for the same patient?

Billing CPT 90836 and 99213 Together: Not Correct as Described

You cannot bill CPT code 90836 (psychotherapy, 45 minutes) and 99213 (office visit) separately for the same encounter—this represents incorrect coding that will likely result in claim denials or audit issues. The correct approach depends on whether you're providing psychotherapy with medication management during the same session.

The Correct Coding Framework

If Providing Both Psychotherapy AND Medication Management:

You should use add-on psychotherapy codes combined with E&M codes, not standalone psychotherapy codes:

• Use 90833 (16-37 minutes of psychotherapy) or 90836 (38-52 minutes of psychotherapy) as add-on codes to your E&M service (99213)
• Bill as: 99213 + 90836 (not 90836 alone with 99213)
• The add-on psychotherapy codes (90833,90836,90838) are specifically designed to be billed with E&M codes when both medication management and psychotherapy occur in the same visit 1

If Providing Only Psychotherapy:

• Use standalone psychotherapy codes: 90832 (30 minutes), 90834 (45 minutes), or 90837 (60 minutes)
• Do not bill an E&M code alongside these

Key Documentation Requirements:

To bill the combined codes (E&M + add-on psychotherapy) appropriately:

1. Document the E&M component separately: Include medical decision-making elements, medication review, side effects, vital signs if relevant, and medical management
2. Document the psychotherapy component separately: Note the therapeutic techniques used, patient response, and time spent in psychotherapy
3. Time documentation is critical: The psychotherapy time must meet the minimum threshold (38 minutes for 90836) 1, 2
4. Total time matters: Your total encounter must support both services

Common Pitfalls to Avoid:

• Don't bill standalone psychotherapy codes (90832,90834,90837) with E&M codes—this will be denied
• Don't use 99213 alone if you're spending 45 minutes doing psychotherapy—you're undervaluing your work
• Clinical psychologists and clinical social workers cannot bill 90836 at all under Medicare rules, as they cannot provide medical services 3
• Insufficient documentation of distinct E&M and psychotherapy components will trigger audits

Practical Billing Algorithm:

For your scenario (45 minutes psychotherapy + brief medication review):

1. If medication review involves medical decision-making (adjusting doses, reviewing labs, assessing side effects): Bill 99213 + 90836
2. If you're only doing psychotherapy with minimal medication discussion: Bill 90837 (60-minute standalone psychotherapy code if total time supports it) or 90834 (45-minute code)
3. Document total time and break down how much was psychotherapy versus medical management

The evidence shows that the 2013 CPT code changes specifically created this add-on structure to allow psychiatrists to bill for combined services appropriately 1, 4. Using the wrong combination will result in claim denials and potential compliance issues.