PMHNP Billing Guide
PMHNP Billing & Coding: The Complete 2026 Guide
How PMHNP billing actually works: direct vs incident-to, the codes you use every day, whether Medicare and Medicaid cover you, and the denials that quietly drain a psychiatric nurse practitioner practice.
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Why PMHNP Billing Is Different
If you are a psychiatric-mental-health nurse practitioner, you can bill most of the same CPT codes a psychiatrist bills. What changes is the money and the rules around it. Two things drive almost every PMHNP billing question: how the claim is billed (under your own NPI, incident-to a physician, or as a split/shared visit), and which payer is on the other end. Get those two right and you collect what you earn. Get them wrong and you either leave money on the table or invite an audit.
This guide walks through the reimbursement difference, the codes PMHNPs use most, Medicare and Medicaid coverage, and the denials we see most often.
The 85% Question
Direct Billing vs Incident-To: The Reimbursement Difference
This is the single most important concept in PMHNP billing, and it applies to Medicare specifically.
Direct billing (under your own NPI). When a PMHNP furnishes a service billed under the nurse practitioner’s own NPI, Medicare pays 85% of the amount a physician would receive under the Physician Fee Schedule. This rate was set by the Balanced Budget Act of 1997 and is codified at 42 CFR 414.56. It applies regardless of your state’s scope-of-practice laws (CMS APRN; 42 CFR 414.56).
Incident-to billing (100%, with strings attached). When a PMHNP’s service is billed “incident to” a physician’s services in an office setting, Medicare can pay 100% of the fee schedule. That extra 15% is not free. Incident-to requires that the physician personally saw the patient and established the plan of care, that the PMHNP is following that plan for that problem (no new diagnoses or new problems), that the physician provides direct supervision (present in the same office suite and immediately available), and that the physician remains actively involved. The service is billed under the physician’s NPI (CMS Incident To).
Because incident-to has real compliance exposure, many PMHNP practices bill directly under the NP’s NPI, accept the 85%, and sleep at night. Which approach is right depends on your setting, your ownership structure, and your risk tolerance.
Commercial payers and Medicaid. The 85% figure is a Medicare rule. Commercial insurers set their own fee schedules and NP reimbursement percentages, which vary by plan. Medicaid reimbursement is set by each state. Do not assume the Medicare 85% applies to a commercial or Medicaid claim; check your specific contract and your state’s policy.
The Codes
CPT Codes PMHNPs Use Most
Descriptions here are paraphrased summaries for orientation only; the official descriptors and rules are owned by the American Medical Association (CPT) and should be confirmed in the current AMA CPT code set and your payer’s policy. CPT is a registered trademark of the AMA.
| CPT Code | What It Covers (Paraphrased) | PMHNP Notes |
|---|---|---|
| 90791 | Psychiatric diagnostic evaluation without medical services | Intake/eval without a medical component. Prescribing PMHNPs generally use 90792 instead. |
| 90792 | Psychiatric diagnostic evaluation with medical services | The typical intake code for prescribing PMHNPs, because it includes medical services. |
| 99202–99215 | E/M office visits, new (99202–99205) and established (99211–99215) | Medication-management and follow-up visits. Level set by medical decision making or total time. |
| 90833 | Psychotherapy ~30 min, add-on to an E/M service | Add-on only. Reported with an E/M code when therapy and med management happen together. Document therapy time separately. |
| 90836 | Psychotherapy ~45 min, add-on to an E/M service | Add-on to E/M. Time on the E/M portion is not counted toward psychotherapy time. |
| 90838 | Psychotherapy ~60 min, add-on to an E/M service | Add-on to E/M. |
| 90832 / 90834 / 90837 | Standalone psychotherapy ~30 / 45 / 60 min | Used when psychotherapy is the service, without a same-visit E/M. See 90834 vs 90837. |
| 90853 | Group psychotherapy | Per-patient group therapy. Check payer limits on group size and documentation. |
Sources: CMS A57520 and the current AMA CPT code set. Add-on codes 90833, 90836, and 90838 are reported in addition to an E/M code, and psychotherapy time must be documented separately from E/M time.
Coverage
Can PMHNPs Bill Medicare and Medicaid?
Medicare: yes. Nurse practitioners are recognized Medicare providers. You enroll through PECOS, typically via the CMS-855I, which establishes your enrollment and assigns your PTAN. If reassigning billing rights to a group, that group also files a CMS-855R. A complete PECOS submission often processes in about a week; missing information can push it toward 35 days (CMS MLN).
Medicaid: usually, but it varies by state. Every state Medicaid program reimburses nurse practitioners, but enrollment, covered services, reimbursement rate, and supervision requirements are set state by state. Confirm your specific state Medicaid policy before you rely on a coverage or payment assumption.
Commercial payers: yes, once credentialed. See our credentialing service and the CAQH ProView walkthrough.
Stop the Leaks
Top PMHNP Billing Denial Reasons
Enrollment and Credentialing Gaps
Billing before enrollment is active, or after a CAQH attestation lapsed, gets claims denied as “provider not eligible.” The most preventable denial and the most common.
Invalid Incident-To
Billing incident-to when the patient had a new problem, or when no supervising physician was in the office suite, fails the requirements and is a compliance risk, not just a denial.
Missing Psychotherapy Time
Add-on codes 90833, 90836, and 90838 require documented psychotherapy time separate from the E/M work. Without a start/stop or total therapy time, the add-on gets denied.
Wrong Eval Code
Using 90791 when medical services were part of the intake, or 90792 without documenting the medical component, triggers denials and downcoding.
Medical Necessity Mismatch
A diagnosis that does not support the service, or documentation that does not match the level billed, draws denials and records requests.
Frequency and Payer Limits
Some payers cap the frequency of certain psychotherapy or group codes, or bundle services. Claims that exceed limits deny even when the care was appropriate.
Informational only. This guide is general information about PMHNP billing and coding, not billing, coding, legal, or medical advice. Coding rules, coverage, and payment change and vary by payer and state. Verify every code and rule against the current AMA CPT code set, your CMS Medicare Administrative Contractor, your state Medicaid program, and your payer contracts before billing. CPT is a registered trademark of the American Medical Association. Last reviewed: July 2026.
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