Here is the updated help center article with the horizontal line breaks removed, and I went ahead and added the recommended title at the top:
Why billing 99215 with 90838 triggers payer scrutiny
When 99215 (high-complexity E/M) and 90838 (60-minute add-on psychotherapy) are billed together, the visit represents one of the most resource-intensive outpatient services a psychiatric prescriber can report.
While this combination is allowed, it is relatively uncommon in typical outpatient psychiatric care and is frequently reviewed during payer audits. Because both codes represent the highest levels of service, payers often look closely at documentation to confirm that the services billed accurately reflect the care provided.
For this reason, this combination is generally reserved for visits where both high medical complexity and extended psychotherapy are clearly necessary and supported by the record. Below are several reasons why this pairing may attract additional scrutiny:
It represents the highest levels of both services
When billed with psychotherapy, 99215 must be supported by high-complexity medical decision making (MDM).
When psychotherapy is reported with an E/M service, time cannot be used to determine the E/M level. The E/M code must be selected based on MDM only.
90838 requires at least 53 minutes of psychotherapy.
When these codes are billed together, the documentation must support both high-complexity medical decision making and extended psychotherapy time within the same visit.
Because these represent the highest levels of each service type, payers often review these claims to confirm the documentation reflects the intensity of services billed.
The services must be clearly distinct
When psychotherapy is billed with an E/M service, documentation must demonstrate that two separate services occurred during the visit.
The E/M portion typically includes:
Evaluation of psychiatric symptoms
Medication management
Risk assessment and safety considerations
Clinical reasoning behind treatment decisions
The psychotherapy portion should describe:
The therapeutic interventions used
The symptoms or behaviors addressed
The patient’s response to those interventions
Extended psychotherapy time should be clinically clear
To report 90838, the psychotherapy portion of the visit must include at least 53 minutes of psychotherapy.
For many psychiatric prescribers, visits are typically focused on evaluation and medication management, with shorter psychotherapy interventions incorporated as appropriate. Because of this, extended psychotherapy sessions may draw additional attention during payer review. When 53 minutes or more of psychotherapy is documented, the record should clearly reflect why that amount of therapeutic time was clinically necessary.
Documentation should reflect the depth of the therapeutic work When extended psychotherapy time is billed, documentation should reasonably reflect the scope and progression of the therapy provided, including:
The specific symptoms, behaviors, or crises addressed
The therapeutic techniques or modalities used
The patient’s responses to those interventions
The clinical focus of the therapy throughout the session
The therapy-specific measurable treatment goals being addressed (separate from medication management goals)
An assessment of the patient’s progress toward those therapy goals
If a note contains only brief statements about therapy but reports 53 or more minutes of psychotherapy, auditors may question whether the documentation actually reflects the level of service billed.
Payers monitor outlier billing patterns
Payers often use analytics to identify billing patterns that fall outside typical practice patterns.
Most psychiatric prescriber visits fall within low or moderate E/M levels, often paired with shorter psychotherapy add-on codes.
Providers who frequently bill the highest levels of both E/M and psychotherapy services may appear as statistical outliers.
Being a statistical outlier can trigger:
Pre-payment review
Post-payment audits
Requests for documentation
Summary: Because this pairing represents the highest levels of both services, many psychiatric providers reserve it for visits involving unusually complex clinical presentations or significant therapeutic intervention.