Family Therapy Billing: When to Use 90846 vs 90847

Introduction

Determining whether to bill CPT 90846 or 90847 often causes confusion for behavioral health providers and practice administrators. A practitioner might spend an hour meeting with a pediatric patient’s parents to discuss behavioral interventions at home and wonder: Can I bill this under the child’s insurance if the child wasn’t in the room? The operational distinction between these two primary family therapy codes rests on one pivotal factor: whether the identified patient (IP) is physically or virtually present during the session. Misrepresenting patient presence can lead to audit exposure, claim denials, or improper reimbursement. Understanding the documentation expectations, payer nuances, and clinical intent behind 90846 and 90847 ensures smooth claims processing and compliant billing workflows.

Understanding the Operational Distinction

Both codes describe family psychotherapy services lasting approximately 50 minutes (typically spanning 45 to 50 minutes in standard clinical practice). However, the mechanics of who occupies the room dictates your coding choice.

• CPT 90846 (Family psychotherapy without patient present): Billed when the identified patient is absent for the duration of the encounter, and the provider meets exclusively with family members or guardians.
• CPT 90847 (Family psychotherapy with patient present): Billed when the identified patient is physically or virtually present and actively participating for all or part of the session alongside family members.

CPT 90846: Family Psychotherapy Without Patient Present

CPT 90846 is billed when the therapist meets exclusively with family members, guardians, or significant others to discuss the identified patient’s treatment. Even though the patient is absent, the session must directly support the treatment plan of the identified patient.

Hypothetical Example: A therapist meets with the parents of an adolescent undergoing treatment for severe anxiety to train them on exposure therapy support strategies. The adolescent does not attend. The therapist bills 90846 under the adolescent’s insurance policy.

CPT 90847: Family Psychotherapy with Patient Present

CPT 90847 is billed when the therapist conducts family therapy and the identified patient actively participates in the session alongside family members.

Hypothetical Example: A therapist meets with a husband and wife to address marital dynamics contributing to the husband’s major depressive disorder. Because the husband (the identified patient) is actively participating in the session alongside his spouse, CPT 90847 is the appropriate code.

What About Split Sessions? (When a Patient Leaves or Joins Mid-Session)

A common clinical scenario involves a provider spending 20 minutes alone with family members, followed by 30 minutes with both the family and the patient present in the same appointment block.

When a single session includes time both with and without the patient, bill CPT 90847. CPT guidelines dictate that if the identified patient is present for a meaningful portion of the family therapy session, the entire encounter is reported using 90847.

What NOT to do:

• Do not unbundle: Do not bill both 90846 and 90847 for the same date of service unless two separate, distinct encounters occurred and meet explicit payer criteria for multiple daily sessions (which often requires modifier usage and strict justification).
• Do not combine individual and family codes: Do not bill CPT 90837 (Individual Psychotherapy) and CPT 90847 for the same time frame simply because you spent part of the time alone with the patient.

Documentation Standards for 90846 and 90847

Proper documentation is your primary defense during routine payer reviews or audits. Payers routinely scrutinize family therapy billing rules to ensure services are medically necessary and billed under the correct member profile.

Every progress note for 90846 or 90847 should clearly record:

• Time and Duration: Explicit start and stop times or total session duration (must meet the time threshold for the code).
• Participants: Explicitly list everyone present in the session (e.g., “Jane Doe [Mother], John Doe [Father]; Identified Patient [Child] absent”).
• Identified Patient Focus: Explicitly detail how the discussion directly relates to the identified patient’s diagnosis, treatment goals, and behavioral plan.
• Clinical Rationale (for 90846): Document why it was clinically necessary to hold the session without the patient present (e.g., discussing sensitive behavioral intervention plans that require parental coordination without escalating the child’s anxiety).

Payer Considerations & Common Denial Triggers

While CPT coding rules are standardized by the American Medical Association (AMA), commercial health plans, Medicaid programs, and Medicare Advantage plans maintain individual coverage policies regarding family therapy.

1. The “Identified Patient” Requirement

Family therapy is billed under the primary insurance policy of the identified patient, not the family member attending the session. If you meet with parents regarding a child’s mental health care, the claim goes under the child’s member ID, listed with the child’s primary diagnosis code.

2. Frequency and Pre-Authorization Limits

Certain plans place strict frequency caps on 90846 compared to 90847. Some payers view 90846 as an auxiliary service and may require prior authorization if used continuously over extended treatment periods. Always check the payer fee schedule or behavioral health provider portal for authorization triggers.

3. Medical Necessity Rules

Payers may deny CPT 90846 if the documentation suggests the meeting was purely administrative, educational, or focused entirely on the family member’s personal struggles rather than the treatment of the identified patient.

Step-by-Step Action Plan: Handling Claims and Denials

When a claim for 90846 or 90847 encounters processing issues or denials:

1. Review the Explanation of Benefits (EOB) / Electronic Remittance Advice (ERA): Determine the exact reason code (e.g., non-covered service, patient non-member, coding error, or missing authorization).
2. Cross-Reference Progress Notes: Confirm whether the patient was present. If you billed 90846 but progress notes show the patient participated, update the claim to 90847 (or vice versa) and submit a corrected claim.
3. Verify Primary Diagnosis: Ensure the claims clearinghouse shows the identified patient’s primary mental health diagnosis assigned to the service line.
4. Initiate Reconsideration/Appeal: If a legitimate 90846 claim is denied for “patient not present” on a plan that covers 90846, submit a formal appeal accompanied by the session note demonstrating that the service directly targeted the patient’s plan of care.

Summary and Key Takeaways

• Presence determines the code: Use 90846 when the identified patient is absent; use 90847 when the identified patient is present for all or part of the session.
• Single-session rule: If a session transitions from family-only to family-plus-patient, report 90847 rather than trying to split or unbundle billing codes.
• Document intent: Always document who attended and how the collateral session directly advances the identified patient’s treatment plan.
• Bill the patient’s plan: Always submit family therapy claims under the identified patient’s member details and diagnosis codes.

About PrimeCare MBS 

PrimeCare MBS delivers expert medical billing, coding support, claim submission, payment posting, and denial management services tailored to mental health practitioners and healthcare practices. Partnering with a dedicated revenue cycle provider reduces claim rejections and keeps your practice focused on patient care. Managing behavioral health billing guidelines, code updates, and payer-specific documentation criteria can stretch practice resources thin. Call (407) 413 9101 or email sales@PrimeCareMedicalBilling.com to learn more.

Disclaimer: This article is provided for general informational purposes only and should not be interpreted as legal, coding, compliance, reimbursement, or payer-specific billing advice. Coverage policies and claim processing requirements vary by payer and may change over time. Providers should refer to applicable payer guidelines and official CMS requirements, where applicable, before making billing or reimbursement decisions.

Frequently Asked Questions (FAQ’s)

Q1. What is the main difference between CPT codes 90846 and 90847?

A1: CPT 90846 is billed when family therapy occurs without the identified patient present, whereas CPT 90847 is used when the identified patient actively participates in the session.

Q2. Whose insurance should be billed when conducting a family therapy session?

A2: Family therapy must always be billed under the identified patient’s insurance policy and primary mental health diagnosis, regardless of who attends the session.

Q3. Which code should I bill if the patient attends only a portion of the family session?

A3: If the identified patient is present for any meaningful part of the encounter, you should report CPT 90847 for the entire session.

Q4. Can I bill individual therapy and family therapy on the same day for the same patient?

A4: Unbundling both services on the same day is generally not permitted unless separate, distinct sessions occur and meet explicit payer authorization guidelines.

Q5. Why might a claim for CPT 90846 be denied by an insurance payer?

A5: Claims for CPT 90846 are commonly denied if progress notes fail to prove medical necessity or fail to demonstrate how the session directly benefits the absent patient’s treatment plan.