Behavioral Health Billing
PMHNP Billing & Coding: A Practical 2026 Guide
PMHNPs bill under their own NPI with the same CPT codes psychiatrists use: 90792 for the evaluation, an E/M code like 99214 for medication management, and +90833 when therapy happens in the same visit. Medicare pays 85% of the physician fee schedule when you bill directly.
At A Glance
Coding And Claims, Done Right The First Time
- A medication management visit bills an E/M level, such as 99214, plus the 90833 psychotherapy add-on when you also provide therapy.
- The diagnostic evaluation is 90792 when you prescribe and 90791 when no medical services are part of it.
- Direct vs. incident-to is a decision you make and document for each visit, and it changes what Medicare pays.
- Telehealth claims need the right place-of-service code and modifier for each payer.
- You want every claim scrubbed before it goes out and every denial worked, whether the payer is Medicare, Medicaid or commercial.
The 85% Question
Direct Vs. Incident-To: The Reimbursement Difference
This is the most important concept in PMHNP billing, and it’s Medicare-specific.
Direct Billing (85%)
Under your own NPI, Medicare pays 85% of the physician fee schedule (42 CFR 414.56). Simple and low-risk.
Incident-To (100%)
Under the physician’s NPI at 100%, but only with an established plan and no new problems. Behavioral health allows general supervision, so the physician doesn’t have to be in the suite.
Commercial & Medicaid
The 85% rule is Medicare-only. Each plan and state sets its own commercial and Medicaid rates, so check your contract.
Go deeper on incident-to billing for PMHNPs and PMHNP reimbursement rates.
The Codes
CPT Codes PMHNPs Use Most
We’ve paraphrased these for orientation only, so check the exact descriptors in the current AMA CPT code set and your payer’s policy. Want it printable? Grab the PMHNP CPT codes cheat sheet.
| CPT Code | What PMHNPs Use It For |
|---|---|
| 90791 | Psychiatric diagnostic evaluation without medical services. |
| 90792 | Diagnostic evaluation with medical services, the typical prescribing intake. |
| 99202 to 99215 | E/M office visits for medication management and follow-up. |
| 90833 / 90836 / 90838 | Psychotherapy add-ons (~30/45/60 min) with an E/M code; document therapy time separately. |
| 90832 / 90834 / 90837 | Standalone psychotherapy (~30 / 45 / 60 min). See 90834 vs 90837. |
| 90853 | Group psychotherapy, per patient. Check payer limits on group size. |
Full Visibility
See Every Claim From Charge To Paid
Whoever does your billing, you should know where each claim stands: submitted, rejected, denied or paid. Aging and open appeals belong on the same screen, because a denial nobody works turns into a write-off. Our psychiatric billing services report it that way every month. If you’re comparing billers, start with what mental health billing costs across the market.
The Claim Cycle
Three Steps Behind Every Paid PMHNP Claim
Map Codes And Payers
List your visit types, set the direct vs. incident-to rule for each, and write down what every payer requires before the first claim.
Scrub And Submit
Run each claim against the payer’s rules and what the note supports, then submit it clean.
Work Denials And Appeals
Follow up on aging, correct and resubmit denials, and appeal what should have paid.
Stop The Leaks
Top PMHNP Billing Denial Reasons
Enrollment Gaps
Billing before enrollment is active, or after a CAQH/DataSpring attestation lapsed, denies as “provider not eligible.”
Invalid Incident-To
A new problem, or a plan the physician didn’t set, breaks the incident-to rules. That’s a compliance risk on top of the denial.
Missing Therapy Time
Add-ons 90833, 90836, and 90838 need documented psychotherapy time separate from the E/M work.
FAQ
Frequently Asked Questions
Can PMHNPs Bill Medicare?
Yes. Medicare recognizes nurse practitioners as providers, and you enroll through PECOS, usually with the CMS-855I (a group adds the CMS-855R). Under your own NPI, Medicare pays 85% of the physician fee schedule.
Can PMHNPs Bill Medicaid?
Usually, but it varies by state. Every state Medicaid program reimburses nurse practitioners, but each state sets its own enrollment, covered services, rates and supervision rules, so check your state’s policy.
What Is Incident-To Billing?
It bills a PMHNP’s service under the physician’s NPI at 100%, but only when the physician started the plan of care for that problem and stays involved. For behavioral health services, Medicare allows general supervision, so the physician doesn’t have to be in the suite. A new patient or a new problem is never incident to. See incident-to billing for PMHNPs.
The PMHNP CPT Quick Sheet, 2026 Edition
Five pages: the ten codes PMHNPs bill most at a glance, which code fits the visit, the E/M level table, what can be billed together, telehealth and Spravato in 2026, and the questions PMHNPs ask most. We email it to you right away.
Want Us To Run Your PMHNP Billing?
PMHNP practices rarely lose money on the code choice. They lose it on the 90833 billed without the therapy time documented, the incident-to visit that didn’t meet the rules, and the denial nobody appealed.
Our Ongoing Billing service works all of that. It runs from 7% of collections for a solo provider down to 4.5% for groups of 26 to 50, with a $300 monthly minimum for a solo provider.
This page isn’t billing, coding, legal or medical advice. It’s general information. Coding rules, coverage and payment change, and they 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: October 2026.