What CPT codes are used for combined therapy and medication visits?

Bill psychotherapy code (90832 16-37 min, 90834 38-52 min, 90837 53+ min) plus add-on code 99417 for time-based E/M or E/M code with modifier for medication management component. Alternatively, some payers accept billing 90833 (16-37 min) or 90836 (38-52 min) as add-on codes to E/M for psychotherapy performed with E/M service. Document start/stop times.

What documentation is required for combined service billing?

Document: separate notation of therapy component (presenting concerns, interventions used, patient response, progress toward goals) and medication component (current medications, adherence, side effects, symptom response, medication changes). Include session duration with breakdown of time spent on each component if using time-based codes.

How do I document time for combined visits?

Document: total session duration, time spent on psychotherapy versus medication management, start and stop times if using time-based billing. Psychotherapy time includes face-to-face therapy; medication management time includes discussion of medications, side effects, adherence. Be specific about time allocation to support combined billing.

What therapeutic interventions should be documented?

Document: specific therapeutic modality (CBT, DBT, supportive, psychodynamic), interventions used (cognitive restructuring, behavioral activation, skills training, validation), patient engagement and response, homework assigned and reviewed, and progress toward treatment goals. Generic statements ('provided supportive therapy') don't adequately document skilled intervention.

How should treatment integration be documented?

Document: how therapy and medication work together for this patient, treatment goals addressed by each modality, coordination of approaches (e.g., CBT targeting thoughts while medication addresses neurovegetative symptoms), and overall treatment response. This demonstrates integrated care rather than separate parallel treatments.

Combined Therapy Medication Visit Template - Integrated Care

Psychiatry: Therapy and Medication Visit Template

Psychiatry Psychiatry Updated: 11/7/2025

The Combined Therapy and Medication Management Visit Template is designed for psychiatrists and psychiatric nurse practitioners providing both psychotherapy and medication management in a single visit. This template efficiently documents both therapeutic interventions and medication management while supporting appropriate billing for combined services (CPT 90834 or 90837 with medication management). The template includes sections for session focus and therapeutic interventions, patient response to therapy, medication review with adherence and response, side effect monitoring, symptom assessment, treatment plan adjustments for both therapy and medications, and follow-up planning. This template ensures comprehensive documentation of combined services, supports appropriate billing, maintains efficiency for providers offering integrated care, and improves patient outcomes through coordinated treatment. Ideal for psychiatric practices providing integrated care, practices managing patients requiring both therapy and medication, and practices optimizing visit efficiency.

Visit Information

Visit type: Combined therapy and medication management
Session duration: [X] minutes
Session number: [X] of planned sessions

Therapy Component

Session focus: [Main topics discussed]
Therapeutic interventions: [CBT, DBT, supportive, etc.]
Patient response: [Engagement, insight, homework completion]
Progress toward goals: [Assessment]

Medication Component

Current medications: [List with dosages]
Adherence: [Assessment]
Response: [Effectiveness]
Side effects: [Monitoring]
Symptom assessment: [Current symptoms]

Combined Assessment

Overall progress: [Improvement, stability, concerns]
Treatment coordination: [How therapy and meds work together]

Risk Assessment

Suicide risk: [Assessment]
Safety: [If concerns]

Assessment

1) [Primary diagnosis] — Status: [Response to combined treatment]
2) [Other diagnoses]

Plan

1) Therapy: [Continue / Adjust approach]
2) Medication: [Continue / Adjust / Change]
3) Homework: [Assignments]
4) Follow-up: [Next appointment]

Patient Instructions

Treatment plan reviewed. Patient verbalized understanding. Next appointment scheduled.

Psychiatry: Therapy and Medication Visit Template

Template