Question: What code is used for cognitive behavioral therapy for insomnia (CBT-I)?
Answer: There are three different code series that can be used to report cognitive behavioral therapy for insomnia (CBT-I). Some providers report evaluation and management (E/M) codes for new and established patients, as appropriate, for the provision of this service. The Psychotherapy 9083X series, which describes psychotherapy (based on session length), may also be reported for providing CBT-I. These codes may be reported as a standalone or with an E/M code, if the patient receives a medical E/M service on the same day as the psychotherapy service by the same physician or other qualified health care professional. To report both E/M and psychotherapy, the two services must be significant and separately identifiable. The services are reported by using codes specific for psychotherapy when performed with E/M services as add-on codes to the E/M service. 90832 is the only code in this series that cannot be billed in conjunction with an E/M service.
The medical and psychotherapeutic components of the service may be separately identified as follows:
- The type and level of E/M service is selected first based upon the key components of history, examination, and medical decision making.
- Time associated with activities used to meet criteria for the E/M service is not included in the time used for reporting the psychotherapy service. Time may not be used as the basis of E/M code selection, and Prolonged Services may not be reported when psychotherapy with E/M are reported.
- A separate diagnosis is not required for the reporting of E/M and psychotherapy on the same date of service.
Providers have one additional option for reporting CBT-I, as some report this service using Health and Behavior Assessment codes from code series 9615X. E/M services codes should not be reported on the same day as health and behavior assessment/intervention codes 96150 – 96155.
**Please note that the 9083X and 9615X code series are primarily reported by clinical psychologists, psychiatrists, and licensed clinical social workers (LCSWs).