Billing for Extended Sessions
by Barbara Griswold, LMFT (updated June 8, 2023, updates in red)
One of the most common questions I receive from therapists in consultations is how to bill insurance for “extended sessions” – that is, sessions longer than 60 minutes.
Therapists billing for extended sessions were left high and dry in 2013 when the American Medical Association overhauled the Current Procedural Terminology (CPT) code list, and deleted the billing codes for these longer services. CPT codes, which are used on claims and statements to identify the types of services rendered, now offer only three timed codes for individual psychotherapy, the longest one being 90837 for 60 minutes. With instructions to use the 90837 60-minute therapy code for any session over 53 minutes, there was no way to distinguish a 60-minute session from longer sessions, thus insurance reimbursement was based on the 60-minute rate.
However, therapists and clients quickly learned they might not get reimbursed more for a 60-minute session than for a 45-minute session. While many plans do allow ongoing, routine 60-minute sessions, and reimburse more than the 45-minute session (CPT code 90834), other plans reimburse at the same rate. As always, it’s a good idea to contact the plan to check their policy on coverage of 90837 sessions.
Worse yet, at least one major insurance plan (United Behavioral Health/OPTUM) up until December 2018 required preauthorization for use of the 90837. While UBH no longer requires preauthorization for 90837, it seems clear that they do not think this code should be used routinely, and there is an increased chance of audit if you do. In treatment reviews, OPTUM case managers have conveyed that in general 45 minute sessions should be enough for routine therapy, and longer sessions may only be seen as needed for acute crisis, complex cases, clients with Post-Traumatic Stress Disorder, Panic Disorder or Obsessive Compulsive Disorder, or when more complex treatment is being done, such as Prolonged Exposure Therapy, EMDR, or Systematic Desensitization.
A New Billing Possibility
Another billing possibility for extended therapy sessions emerged in 2016 when the AMA allowed add-on codes for Prolonged Services, 99354 and 99355, to be used by non-medical personnel. Formerly allowed to be used only by doctors, physician’s assistants, and nurses, these “add-on codes” are used when billing for services that have gone longer than the usual service. According to the American Academy of Professional Coders (AAPC), the only individual psychotherapy service that could be billed with a Prolonged Service Codes was CPT 90837 (60 minute individual therapy). Not long afterwards, the AMA allowed these codes to be used with family or couples therapy, CPT code 90847. To bill using Prolonged Services codes, the session had to be a minimum of 30 minutes beyond the original code. This means, for a 90837 (60 minutes) the session minimum would be 90 minutes; for a 50-minute 90847, the session must be a minimum of 80 minutes.
Many therapists were able to get reimbursed using these Prolonged Services codes for many years. However, the option of using Prolonged Services Codes was taken away for sessions on or after January 1, 2023. According to the American Medical Association, these two codes were deleted as of 1/1/2023. I have confirmed with coding experts my reading of the new 2023 CPT code manual: that no new CPT code(s) have been created to take their place. While it may appear that code 99417 is replacing these codes, this code can only be used with certain Evaluation and Management (E&M) codes used by doctors, and cannot be used with psychotherapy codes 90837 or 90847 for extended sessions. So, if you’ve been using these codes to bill for longer sessions, please take heed that these codes are no longer billable and will no longer be reimbursed for sessions in 2023, and at this point I see no other coding option. I have conferred with other billing specialists who teach coding on a nationwide level and this is their understanding also. This applies to all insurance plans, and all clients, whether you are in- or out-of-network. Remember, you can still use 99354/99355 to bill for sessions that took place before 1/1/2023, though remember there has never been any guarantee that any plan will reimburse for these codes. Read my article on this situation — click here. To read the AMA notice yourself, click here.
Other Billing Options
If the session meets the criteria for a crisis session, the choice might be made to bill using the crisis CPT codes that were introduced by the AMA in 2013: 90839 for the first 60 minutes of a crisis session, 90840 as the add-on for each 30 minutes of additional time after the 60 minutes. In order for the new crisis codes to apply, the presenting problem must require immediate attention to a client in high distress, including life-threatening or at least highly complex crisis clinical situations.
If you are a network provider, can you bill one 45- or 60-minute session to insurance, and contract privately with the client to pay any additional time out of pocket? There is a lot of discussion online about this option, both sides confident about their opinion. To me, this option seems a credible one, if not forbidden in your plan contract. Why shouldn’t the client retain the right to pay for services that are not covered by his plan? However, since it is a gray area, if you are audited, the health plan may say you violated your contract by charging the client more than their copayment and deductible. Many years ago I did get one insurance network executive say billing clients for extra time would be OK as long as the client signed a Private Pay Agreement stating he understands that this additional time will be his responsibility, and how much he will owe; “if you get that, we would back you,” he said. I have a Private Pay Agreement for such situations available in my Practice Forms Packet, which is available here.
Can you break the session into two parts and bill for both? I’ve talked to therapists who have done this, ex. billing for one 90834 and one 90832 (a 30-minute session) on the same day, or billing for 2 units of 90834 or 90837. In my experience, these scenarios are rarely reimbursed, as most plans only allow one hour of therapy per day (unless the two services are separate and distinct, such as a couples therapy session and an individual therapy session on the same day, in which case, modifier 59 may need to be used to indicate this). However, I have had a therapist or two say that they have been successful getting two units of 90837 paid for the same day. But can you really defend that you provided two separate sessions? And how would you document that? And how nervous would you be if you were audited? I think this would be seen as an attempt to end-run around insurance plan daily limits.
While we can look for different ways to code and bill for these longer sessions, it must be acknowledged that our discussions are the result of an industry-wide trend toward encouraging briefer treatment, and disincentivizing longer sessions.
American Medical Association, CPT® 2019 Standard Edition. Chicago, IL; American Medical Association, 2018.
OPTUM 360 (2018). Current Procedural Coding Expert.
APA Office of Health Care Financing. (2016, November 16). Psychotherapy coding clarifications, telemedicine code modifier added to CPT manual. Retrieved March 20, 2018, from http://www.apapracticecentral.org/update/2016/11-17/telemedicine-code.aspx
OPTUM by United Behavioral Health. (2014, February), Coverage Determination Guidelines, Extended Outpatient Sessions, Retrieved March 20, 2018, from https://providerexpress.com/trans/html/pdf/extendedOutpatientVisits.pdf
Dustman, R. (2016, February 16). Prolonged Services Update and Other 2016 E/M Changes. Retrieved March 20, 2018, from https://www.aapc.com/blog/33732-prolonged-services-updates-and-other-2016-3m-changes/
Specific criteria must be met to use prolonged services code. American Academy of Pediatrics News (January 10, 2018); Retrieved Feb 10, 2019 from http://www.aappublications.org/news/2018/01/10/Coding010518
American Academy of Child and Adolescent Psychiatry. (2018) CPT Training Manual. Retrieved Feb 11, 2019 at https://www.aacap.org/App_Themes/AACAP/docs/clinical_practice_center/business_of_practice/cpt/2018_CPT_module_revised_March_2018.pdf
Direct Prolonged Serices: Inpatient and Outpatient Coding. American Academy of Pediatrics (2016). Retrieved Feb 11, 2019 at https://www.aap.org/en-us/Documents/coding_prolonged_services.pdf
The 2013 Psychotherapy Codes: An Overview for Psychologists. (n.d.). Retrieved March 20, 2018, from http://www.apapracticecentral.org/reimbursement/billing/psychotherapy-codes.aspx