CPT codes for evaluation and treatment

It’s important for mental health practitioners to understand CPT codes for evaluation and treatment. These codes help to ensure you correctly describe and bill for behavioral health services. 

Developing and maintaining an awareness of common mental health CPT codes, including initial evaluation CPT codes, is key. And, you’ll also need to understand the difference between CPT vs. HCPCS codes.

This guide provides a comprehensive overview of CPT codes for evaluation and treatment, and their key differences. 

Additionally, this article includes a handy office visit CPT codes list comprised of the most common CPT code examples. You can quickly download this list and print or save it, so you can find and reference the correct billing codes faster than ever—freeing your valuable time from tedious administrative tasks.

What are CPT codes?

Current Procedural Terminology (CPT) is a coding system created by the American Medical Association (AMA) to describe healthcare procedures, surgery, and diagnostic services. 

Healthcare professionals around the world use CPT codes to ensure standardized language around medical services and procedures, which can improve accuracy, streamline reporting, and allow for data tracking. 

All clinical providers (including behavioral health therapists) use this set of codes for public and private insurance reimbursement. 

Therefore, clinicians need to know initial evaluation CPT codes, along with codes for treatment planning. 

Even if a clinician doesn’t bill insurance, this standardized terminology can be used to provide clients with superbills so that they can submit them directly to their insurance for reimbursement.

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Types of CPT codes

There are three distinct categories of current procedural terminology codes:

• Category I: These codes describe common medical procedures or services (also called CPT-4 codes)

• Category II: Optional codes used to record performance and quality, and to denote services, products, and supplies not otherwise described, such as medical equipment and supplies, ambulatory services, and prosthetics

• Category III: These codes describe new and emerging technology, procedures, and services, however they are not widely used

You may have also heard of HCPCS codes, which are Healthcare Common Procedure Coding System codes. This reporting language was designed by the Centers for Medicare & Medicaid Services (CMS) and is used by providers to classify certain procedures and services most often provided to clients with Medicare or Medical insurance benefits.

List of CPT codes for evaluation and treatment

CPT codes for evaluation and treatment, also known as evaluation and management (E&M) codes, range from 99202 to 99499. These codes can differ based on the treatment facility (inpatient, outpatient, office visit), duration, complexity, and whether the service billed is for ongoing treatment management or requires an initial evaluation CPT code.

Below is a list of evaluation and management coding examples commonly used by mental health clinicians:

Inpatient E&M codes list

• 99221: Inpatient evaluation and management of a low complexity patient, of 30 minutes or less

• 99222: Inpatient evaluation and management with moderate complexity, of 50 minutes

• 99223: Inpatient evaluation and management with extensive complexity, of 70 minutes 

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Outpatient E&M codes list

• 90838: 60-minute psychotherapy with E/M service

• 90791: Psychiatric evaluation

• 90792: Psychiatric diagnostic evaluation with medical services

• 99202: Outpatient E&M for new patient with minimal concerns and assessment and 15-29 minute duration

• 99203: Outpatient E&M for new patient with low complexity, limited assessment, and 30-44 minute duration

• 99204: Outpatient E&M for new patient with moderate complexity, moderate assessment, and 45-59 minute duration

• 99205: Outpatient E&M for new patient with high complexity, extensive assessment, and 60-74 minute duration

• 99212: Outpatient E&M for existing patient with minimal complexity and assessment, of 10-19 minute duration

• 99213: Outpatient E&M for existing patient with low complexity and limited assessment, of 20-29 minute duration

• 99214: Outpatient E&M for existing patient with moderate complexity and assessment, of 30-39 minute duration

• 99215: Outpatient E&M for existing patient with high complexity and extensive assessment, of 40-54 minute duration

Office visit CPT codes list

• 90885: Psychiatric evaluation of records

• 96110: Developmental screening and testing

• 96112: Developmental test administrator of language, fine/gross motor skills, cognition, social, memory, and executive functions - 60 minutes

  • Note: Clinicians may add modifier 96113 for every additional 30 minutes

• 96127: Brief emotional and/or behavioral assessment, such as ADHD, depression measures, scoring, and documentation

• 96105: Assessment of aphasia

• 96125: Cognitive performance testing

• 96116: Neurobehavioral status exam

• 96130: Psychological testing, interpretation, clinician decision making, treatment planning, and interactive feedback with patient and family - 60 minutes

  • Note: Clinicians may add modifier 96131 for every additional 30 minutes

Additional CPT code examples

The following table is a list of CPT codes used by mental health clinicians during office visits (excluding evaluation and management):

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Clinicians may also add a modifier, which provides additional information to both initial evaluation CPT codes and ongoing service descriptors, such as:

• Modifier UT: Describes attending to a patient in crisis

• Modifier GT: Defines a telehealth session using audio and video

• Modifier 25: Used to describe a separate evaluation and management service

  • Note: You can only attach modifier 25 to codes 99201 to 99215 and 99341 to 99350

• Modifier 59: Denotes another service completed with the client on the same day (excludes evaluation and management)

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