Aquatic therapy CPT codes: Coding and documentation guide
Couples therapy creates an odd problem for health insurance: There are clearly two people sitting in the room, but insurance generally wants to know which one of them is the patient.
That’s where things start getting wonky.
Therapists who are comfortable treating couples can still find themselves staring at a claim wondering what exactly the insurance company thinks happened during the past hour. Was it couples therapy? Family therapy? Individual therapy with a spouse present? And, probably most importantly, is couples therapy covered by insurance in the first place?
The short answer is: It often can be, but coverage generally depends on the plan, the purpose of treatment, and whether the service meets the insurer’s requirements for medical necessity.
The longer answer is more useful.
How does insurance view couples therapy?
Clinically, a couple may come to therapy because they can’t stop fighting, they’re having intimacy issues, they’re recovering from an affair, or one partner feels like they’ve become the project manager for the entire family.
Those are perfectly legitimate reasons to seek therapy.
Insurance, however, generally isn’t deciding whether the relationship deserves help. It’s deciding whether it should pay for treatment of a covered member’s mental health condition.
Medicare coverage guidance, for example, clarifies that family psychotherapy is covered when the primary purpose is treating the identified patient's condition—meaning the service exists to support their diagnosis, not just the relationship. That distinction is the piece I wish more therapists understood before they start billing couples work.
You can be doing excellent couples therapy and still not have an insurance-covered service. That's why whether couples therapy is covered by insurance depends on the identified patient.
What is CPT code 90847?
CPT code 90847 family psychotherapy describes conjoint sessions with the identified patient present. Insurers use "identified patient" a little differently than family systems theory does. To a payer, it simply means the person whose diagnosis and benefits the claim is billed under. The code is commonly used for ongoing couples or family sessions when the work is directed toward treating that patient.
Imagine that one partner has significant depression. When they become depressed, they withdraw. Their spouse experiences the withdrawal as rejection and pursues harder (a classic pursue-withdraw cycle). The depressed partner feels criticized, retreats further, and pretty soon both people are reenacting the same miserable 20-minute argument three times a week.
The therapy may look very relational. You may be working with attachment, communication, emotional regulation, repair, or whatever couples modality you practice.
But for insurance purposes, there is still an identified patient whose condition helps establish the medical necessity of treatment.
That leads to the part therapists sometimes understandably dislike.
Someone generally has to carry the diagnosis. Feels bad.
There is typically an insurance diagnosis requirement for couples counseling when you’re seeking reimbursement through a health plan. Coverage rules vary by payer, but insurance-funded family psychotherapy generally requires an identified patient and a diagnosis that supports medical necessity.
One partner becomes the identified patient. The claim is submitted under that patient’s information, and the diagnosis attached to the claim helps establish why treatment is medically necessary.
That does not mean you need to start practicing as though one partner is “the problem.”
This distinction matters clinically.
A diagnosis may be necessary for an insurance claim, but couples therapists still think systemically. One partner may have generalized anxiety disorder, for example, while the couple simultaneously has a pursue-withdraw cycle that neither person created alone.
Your treatment plan can reflect the relational work while still explaining its connection to the identified patient’s symptoms and functioning.
That’s much better than awkwardly pretending the other person in the room is basically furniture.
What about billing 90837 instead?
This is one of the questions that comes up constantly.
CPT code 90837 is used on a claim for individual psychotherapy. CPT code 90847 family psychotherapy describes a different service.
The important question isn’t, “Which one reimburses more?”
It’s, “What did I actually do?”
If you are providing ongoing conjoint couples psychotherapy, routinely billing an individual psychotherapy code simply because the reimbursement happens to be better would not accurately describe the service. Current SimplePractice billing guidance distinguishes ongoing couples and family sessions from individual psychotherapy codes such as 90832, 90834, and 90837.
There are situations where a family member or spouse may participate in an individual psychotherapy session. Maybe you bring a parent into part of a teenager’s session or an established client’s partner joins briefly to help with treatment.
That’s different from conducting couples therapy for most of the session.
The code should follow the service you provided, rather than the service you wish the payer reimbursed better.
A revolutionary concept, I know.
Billing the wrong code won't make couples therapy covered by insurance. It risks a denial.
Why reimbursement can make this confusing
This is where business realities enter the conversation.
Mental health insurance reimbursement varies across payers, individual plans, contracts, geographic areas, and provider arrangements. A therapist may discover that 90847 reimburses differently than 90837, even though couples sessions can feel more demanding clinically.
There isn’t one universal commercial insurance reimbursement rate for couples therapy.
That means therapists shouldn’t assume a code is covered simply because another clinician says they get paid for it. Even clients with the same insurance carrier may have different benefits.
Whether couples therapy is covered by insurance also varies by plan, not just by payer. To find out if couples therapy is covered by insurance for a given client, verify the specific plan.
Ask whether CPT 90847 is a covered benefit for a patient with a mental health diagnosis, and confirm applicable copays, deductibles, authorization requirements, and other limitations.
It is much easier to have that conversation before six sessions have occurred than after six claims have been denied.
What if you’re out of network?
Is couples therapy covered by insurance out of network? Sometimes, through reimbursement, not direct payment.
A client may pay the therapist directly and request a superbill for out-of-network couples therapy. A superbill is a document that can provide an insurer with information such as CPT codes and diagnosis codes so the client can seek possible reimbursement under their out-of-network benefits.
A superbill is not a guarantee of reimbursement.
Clients should verify their benefits beforehand, including whether they have out-of-network coverage, what deductible applies, and whether the service is eligible for reimbursement. Out-of-network requirements vary by payer, and some insurers may have additional requirements for nonparticipating providers.
And yes, this means therapists occasionally have to explain deductibles, allowable amounts, coinsurance, and superbills while simultaneously trying to help people repair their marriage.
Graduate school really prepared us well for this, didn’t it! Luckily, lots of this info can be found in SimplePractice.
What does couples therapy cost without insurance?
When couples therapy isn't covered by insurance, private pay is the alternative. The couples therapy cost without insurance is ultimately determined by the therapist’s private-pay fee rather than an insurer’s contracted reimbursement rate.
For some couples, paying privately is actually preferable. It can allow therapy to focus entirely on the relationship without requiring treatment to be organized around one partner’s diagnosable mental health condition. That distinction deserves more attention because not every relationship problem is evidence of psychopathology. Sometimes two healthy people are stuck. And sometimes a couple wants premarital counseling, wants to communicate better, or wants help deciding whether to stay together. Proactive reasons can be worthwhile reasons for therapy even when they don’t satisfy an insurer’s definition of medical necessity.
In those situations, private pay may simply be the cleaner arrangement.
Keep the clinical reality and the insurance reality separate
The easiest way I’ve found to think about all of this is to hold two ideas at once.
Clinically, you’re treating the couple.
Administratively, when insurance is paying, you’re generally providing a covered health care service connected to an identified patient’s condition.
Those realities overlap, but they’re not identical.
Document the therapy you actually provided, and then connect the intervention to the identified patient’s (remember, from the insurance’s perspective) diagnosis and functioning when that’s what makes the service medically necessary. Use the CPT code that accurately reflects the service. And verify the individual payer’s rules rather than assuming that “couples therapy is covered” means the same thing across every plan.
And remember: Two people can walk into your office as a couple, but the insurance company still wants to know which one is the patient.
So, is couples therapy covered by insurance? It can be, as long as someone is the identified patient.
Sources
Centers for Medicare & Medicaid Services. (2025). Psychiatry and psychology services (LCD L34616). Medicare Coverage Database.
Christensen, A., Atkins, D. C., Baucom, B., & Yi, J. (2010). Marital status and satisfaction five years following a randomized clinical trial comparing traditional versus integrative behavioral couple therapy. Journal of Consulting and Clinical Psychology.
Rathgeber, M., Bürkner, P.-C., Schiller, E.-M., & Holling, H. (2019). The efficacy of emotionally focused couples therapy and behavioral couples therapy: A meta-analysis. Journal of Marital and Family Therapy.
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