By the Coding and Reimbursement Advisory Committee
Cognitive behavioral therapy for insomnia (CBT-I) is the first-line, evidence-based treatment for chronic insomnia. Unlike pharmacological approaches, CBT-I focuses on identifying and modifying the thoughts and behaviors that perpetuate sleep difficulties. It has been shown to produce marked improvements in sleep initiation, sleep maintenance, and overall quality of life, with benefits that extend beyond the treatment period.CBT-I is typically delivered in individual or group formats over six to eight sessions, either in-person or via telehealth. The initial session (60-90 minutes) often includes clinical intake, diagnostic measurements, and patient orientation to CBT-I, including sleep diaries. Subsequent sessions (30-60 minutes) focus on specific interventions and progress monitoring.

Core components of CBT-I

CBT-I is a multi-component therapy, and sessions usually include the following:

  • Sleep hygiene training: Modifying environmental and lifestyle factors that interfere with sleep.
  • Stimulus control: Strengthening the association between bed and sleep, while reducing wakefulness in bed.
  • Sleep restriction therapy: Limiting time in bed to consolidate sleep and improve efficiency.
  • Cognitive therapy: Addressing unhelpful thoughts, beliefs or worries that interfere with sleep.
  • Relaxation techniques: Progressive muscle relaxation, breathing exercises, or mindfulness exercises.

Billing considerations

The first step in CBT-I billing is identifying the correct CPT codes. Different code series are used; some providers report evaluation and management (E/M) codes for new and established patients. The psychotherapy code set may also be reported; these codes may be reported as a standalone or with an E/M code, if the patient is seen for a medical E/M service on the same day as the psychotherapy session by the same physician or qualified health care professional. The two services must be significant and separately identifiable to report both a psychotherapy session and an E/M. The services are reported by using codes specific to psychotherapy when performed with an E/M service, as an add-on code to the E/M service.

CPT codes for reporting CBT-I

E/M codes

  • Some physicians report new or established patient E/M codes (9920X, 9921X series) when a physician or qualified health care professional delivers CBT-I.
  • Use when the encounter is primarily medical but incorporates CBT-I strategies.
  • Documentation must support medical decision-making or time.

Psychotherapy codes (9083X series)

  • 90832: 30 minutes (cannot be billed with E/M codes)
  • 90834: 45 minutes
  • 90837: 60 minutes
  • 90834 and 90837 can be reported as a standalone service OR as add-on psychotherapy codes when provided with an E/M visit.
  • To bill both the psychotherapy and E/M codes, they must be significant and separately identifiable, and time requirements must be met.

Health and behavior assessment/intervention codes (96156-96171)

Used if CBT-I is provided in a behavioral health framework related to a medical condition (e.g., insomnia as a symptom of sleep apnea).

Documentation requirements

Documentation for CBT-I must include evidence that the assessment is reasonable and necessary. At a minimum, it should note the date of the initial diagnosis of physical illness (i.e., insomnia), provide a clear rationale for why the assessment is required, and describe the assessment outcome, including the patient’s mental status and ability to understand and respond meaningfully to treatment. The documentation should also outline the goals and expected duration of the specific psychological intervention.

For intervention services, the documentation must include evidence supporting medical necessity. This should demonstrate proof that the patient has the capacity to understand and respond meaningfully to treatment, describe a clearly defined psychological intervention plan, state the goals of the intervention, and establish the expectation that the intervention will improve adherence to the medical treatment plan. It should also summarize the patient’s response to the intervention and include a rationale for the frequency and duration of services.

Billing pitfalls

  • Using the wrong code set
    • Some providers bill E/M codes when the service is primarily psychotherapy. This may not pass payer review.
    • Some providers default to psychotherapy codes, but not all payers cover the codes when rendered by non-mental health professionals.
  • Failure to separate services
    • Both can be billed when an E/M and psychotherapy session occur in the same visit, but only if the E/M work is significant and separately identifiable. Modifier 25 is appended to the E/M.
    • Without clear documentation, auditors may downcode or deny one of the services.
  • Time documentation errors
    • Psychotherapy codes are time-based, and providers will often round incorrectly (“about 45 minutes”) without stating the exact time.
    • Forgetting to count only face-to-face psychotherapy time (excluding charting, prep or unrelated discussion).
    • Missing time statements are a common denial trigger.
  • Credentialing/scope issues
    • Psychologists, social workers and some advanced practice providers can bill psychotherapy codes.
    • Physicians can bill psychotherapy codes, but auditors may question if their training/scope includes behavioral therapy (documentation must justify it).
    • Non-licensed behavioral coaches generally cannot bill insurance for CBT-I.

Coding scenario

The example below illustrates how CPT codes can be applied in real-world scenarios involving CBT-I.

A 52-year-old female with chronic insomnia for 8 years presents with difficulty falling asleep (takes 90 minutes on most nights), frequent awakenings and daytime fatigue. She’s tried multiple sleep aids (zolpidem, trazodone) with limited benefit. Her medical history includes hypertension and mild sleep apnea treated with CPAP.

The treatment plan is as follows:

  • Initial intake (60-90 minutes): Sleep diary started; patient education on insomnia cycle and CBT-I overview
  • Session 2 (45 minutes): Stimulus control (bed only for sleep; leave bed if awake for greater than 20 minutes
  • Session 3 (45 minutes): Sleep restriction therapy (set a consistent 6-hour sleep window to consolidate sleep)
  • Session 4 (45 minutes): Cognitive restructuring
  • Session 5 (45 minutes): Relaxation training
  • Session 6-8 (30-45 minutes each): Review progress, adjust sleep window, reinforce coping strategies

Appropriate CPT codes: Psychotherapy codes 90834 (45 minutes) or 90837 (60 minutes). If the physician adjusts CPAP settings or antihypertensive meds at a visit, bill E/M codes + add-on psychotherapy code 90836 with modifier 25. The documentation should highlight the diagnosis of insomnia, the CBT-I techniques used, the patient’s progress, and the time spent on the diagnosis.

Conclusion

CBT-I is the first-line, evidence-based treatment for chronic insomnia, addressing behaviors and thoughts that disrupt sleep. Delivered over six to eight sessions, CBT-I combines sleep hygiene, stimulus control, sleep restriction, cognitive therapy and relaxation techniques.

Billing options include E/M codes when medical decision making is central, psychotherapy codes (90832-90838) for time-based therapy, or health and behavior codes (96156-96171) when linked to a medical condition. Documentation must support medical necessity, patient capacity, goals and expected benefits, ensuring compliance and appropriate reimbursement.