There is often significant confusion around billing the interactive complexity add-on code (+90785) particularly when it is reported in addition to psychotherapy. The guidelines below should clarify common questions and support correct coding and documentation.

+90785 actually captures one or a combination of:

• Maladaptive or emotionally charged communication that disrupts treatment (e.g., repeated derailment, refusal to participate without active containment).
• Caregiver emotions or behaviors that interfere with the session and require active management.
• Disclosure of a sentinel event that triggers mandatory reporting during the encounter.
• Significant communication barriers requiring special strategies (e.g., structured play-based methods, AAC device support, simplified language with repeated clarification).

Common misunderstandings: What +90785 is not 

In general, +90785 is not supported by statements such as:

• “The session was difficult.”
• “The client was emotional.”
• “The client talked a lot.”
• “I spent extra effort or time.”
• “The topic was intense or traumatic.”

Remember: Interactive complexity is about how the session had to be managed (process control and interactional barriers), not how hard it felt.

Conclusion

As a rule of thumb, if psychotherapy could have proceeded normally without extra interactional control, +90785 does not apply. When it does apply, your note should read like a clear explanation of what barrier occurred, what you did to manage it, and why those actions were necessary for the therapeutic work to continue.

There appears to be a considerable amount of confusion when it comes to billing psychotherapy codes, especially when used as an add-on code in conjunction with an evaluation and management code. The guidelines below should help to clarify any coding questions regarding this issue.

Coding for Evaluation and Management (E/M)

• In accordance with the 2021 American Medical Association (AMA) E/M coding changes for new and established E/M codes (99201-99215), psychiatric providers should perform a medically appropriate history and/or psychiatric examination with the goal of establishing medical necessity.
• The code selection no longer depends on the level of history or psychiatric exam.
• You should not consider comorbidities and underlying diseases when you select the E/M level unless they are addressed (evaluated or treated) during the visit.
• When performing an E/M alone, the level is based on medical decision making or time.
• To comply with the coding changes, documentation is very important to support the E/M level billed.

Coding for psychotherapy

CPT describes psychotherapy as “the treatment of mental illness and behavioral disturbances in which the physician or other qualified healthcare professional, through definitive therapeutic communication, attempts to alleviate the emotional disturbances, reverse or change maladaptive patterns of behavior, and encourage personality growth and development.”

Per CPT, psychotherapy codes are time-based. For psychotherapy to be supported in the medical record, there must be documentation of therapeutic maneuvers, a periodic summary of goals, indication of progress, and/or documentation of a treatment plan. The time spent providing psychotherapy must be documented.

Coding for E/M with psychotherapy performed on the same day

To bill an E/M and an add-on psychotherapy code, the two services must be significant and separately identifiable AND the time spent for each must be separate. The time used for medical management may not be included in the time of the psychotherapy. If less than 16 minutes are spent providing psychotherapy, the add-on psychotherapy cannot be billed. Additionally, the E/M level must be selected based on MDM and not time.

Example: Patient is seen in the office for an E/M visit with psychotherapy. The nature of the patient’s reason for visit and documentation meet criteria for a 99212 level E/M code. In addition to time spent on the E/M portion of the visit, 20 minutes are spent providing psychotherapy services. Both codes 99212 and 90833 (30 minutes psychotherapy add-on) are reported.

Documentation should include:

• Therapeutic modality (e.g., CBT, DBT, supportive therapy)
• Interventions used
• Treatment goals addressed
• Patient response or progress
• CMS requires psychotherapy and E/M services to be significant and separately identifiable. Blended or indistinguishable documentation of both services continues to be a noticeable issue. Documentation must provide clear E/M vs psychotherapy sections.

CPT and CMS requirements:

• Psychotherapy time must be:
  • Spent exclusively providing psychotherapy.
  • Face-to-face with the patient (or a real-time televisit)
• Psychotherapy time does not include:
  • Post‑visit documentation time
  • Chart review
  • Care coordination
  • Administrative work
  • Time spent performing E/M activities

Time for E/M and psychotherapy services must be separately accounted for. The same minutes cannot be counted toward both services.

Conclusion

• Psychotherapy codes do not include documentation time.
• Documentation time cannot be counted toward psychotherapy minutes.
• When E/M and psychotherapy add‑on codes are billed:
  • Psychotherapy time = face‑to‑face therapeutic services only
  • E/M level = MDM only
• Using documentation time to reach higher billing levels is not compliant.
• Notes lacking psychotherapy content do not support psychotherapy billing, even if time is listed.

Supportive therapy vs. psychotherapy

It is important to recognize the difference between supportive therapy and psychotherapy for proper coding and billing purposes.

Psychotherapy is a structured, goal‑directed clinical treatment for a diagnosable mental health condition using recognized therapeutic techniques. Psychotherapy requires intentional therapeutic work, such as:

• Use of a recognized psychotherapy modality
• Active intervention targeting symptoms or behaviors
• Treatment goals linked to a mental health diagnosis
• Documentation of patient response or clinical progress

Supportive therapy is emotional support and reassurance that, by itself, does not meet CPT psychotherapy requirements and is generally considered part of E/M counseling or patient management. Supportive therapy typically includes:

• Listening and emotional reassurance
• Validation of feelings
• Encouragement and general coping advice
• Discussion of life stressors without structured intervention

Important: While supportive elements may be present during psychotherapy, support alone does not justify CPT psychotherapy codes.