Billing and coding
How to use CPT code 90863 for psychiatric care
Learn how to properly use CPT code 90863 for pharmacologic management with psychotherapy.
July 14, 2025
7 min read
As a prescribing behavioral health provider, you have the ability to combine two gold-standard treatments — psychotherapy and pharmaceuticals — to support your patients. While some individuals may benefit from psychotherapy alone, others may need both medication and therapy.
How you bill insurance payers for these services can vary from appointment to appointment. If you conduct both psychotherapy and medication management in one session, and if you work in an inpatient setting, then you may use CPT code 90863 rather than the standard E/M + add-on therapy code used by solo providers in the outpatient setting.
Before you bill with this code, it’s important to understand what it represents and when to use it. Below, learn more about how to use CPT code 90863 for psychiatric care.
Understanding CPT code 90863: What it is and when to use it
CPT code 90863 represents medication management — including new prescriptions and review of current medications and their effects — when it’s performed with psychotherapy services. It’s typically used in integrated care and facility settings rather than outpatient therapy practices.
Code 90863 is an add-on code to the primary psychotherapy service code — not as a standalone service. In other words, it’s used when you’re providing psychotherapy and addressing medication in the same appointment. Because it involves prescriptions, this code is used by prescribing providers, such as psychiatrists and psychiatric nurse practitioners. In collaborative or facility settings, 90863 may be used when a therapist provides therapy and a prescriber manages medication during the same session. Both must document their contributions, and billing rules may vary by payer.
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Documentation requirements for CPT code 90863
Proper documentation that justifies the service you provided is the best way to ensure timely reimbursement from insurance payers.
Because code 90863 is an add-on code, it must always be billed with another psychotherapy code. Include the code that best represents the time spent with your client, along with all the documentation required for the therapy session, including:
- Session duration
- Modalities used
- Presenting problems/symptoms
- Interventions provided
- Client response/progress
- Plan for next steps
For the medication management section of the appointment, include all pertinent details about your patient’s medication regimen, including:
- Current medications (names, doses, adherence)
- Assessment of side effects, efficacy, and tolerability
- Mental status exam elements relevant to medication evaluation
- Clinical reason for medication adjustments or refills
- New prescriptions or dose changes, if applicable
- Discussion of risks and benefits with patient
- Patient response and understanding of medication plan
Common mistakes when using CPT code 90863
One of the most common mistakes when using CPT code 90863 is using it as a standalone code and failing to include a psychotherapy code such as CPT code 90832, 90834, and 90837.
It’s also important not to pair CPT code 90863 with an incompatible primary code — for example, you can’t use this code as an add-on to E/M codes.
Insufficient documentation that does not properly justify why you used this code is another common error when using CPT code 90863. It’s important to include all the backup required by payers in your documentation, including the patient’s diagnosis, your treatment plan, and notes from the psychotherapy session and medication management discussion.
Insurance reimbursement considerations
Insurance reimbursement for CPT code 90863 can vary widely depending on factors like insurance payer and plan, geographic location, and the prescribing provider’s background.
Typically, reimbursement rates are lower than E/M services. To avoid denials, it's essential to follow payer-specific rules, document both psychotherapy and medication management clearly, and avoid pairing it with E/M codes.
Alternative coding options to consider
If you aren’t a prescribing provider, or your practice management system doesn’t support code 90863 (Headway, for example, does not), you can consider using alternative coding options for medication management.
E/M codes — or evaluation and management services — represent “Office/other outpatient services” in the CPT codebook. They’re commonly used when evaluating a patient’s health rather than providing a service like psychotherapy.
CPT codes 99202-99205 can be used for new patient appointments as long as medication management is part of the visit. You can use CPT codes 99211-99215 for established patients when you discuss medication. Either code can be used for medication management, even if you do not provide psychotherapy.
When you do conduct psychotherapy, you can use an E/M code in tandem with an add-on psychotherapy code, such as 90833, 90836, or 90837.
Resources for further learning and support
While coding is an essential part of getting paid as a behavioral health provider, navigating CPT codes can be challenging and time-consuming. To learn more about coding as a therapy provider, visit Headway’s library of resources, including:
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This content is for general informational and educational purposes only and does not constitute clinical, legal, financial, or professional advice. All decisions should be made at the discretion of the individual or organization, in consultation with qualified clinical, legal, or other appropriate professionals.
© 2025 Therapymatch, Inc. dba Headway. All rights reserved. No part of this publication may be reproduced without permission.
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