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Medicare Pays an LCSW 75 Percent: What 90837 Collects in Your Locality

Summary

Medicare pays a licensed clinical social worker 75 percent of the fee-schedule amount for a clinical psychologist for CPT 90837, then pays 80 percent of that, and the patient owes the rest. No single dollar amount is right nationwide, because the psychologist's rate depends on locality and the year's conversion factor: look up 90837 for your MAC locality in the CMS PFS Look-Up Tool and take three quarters of it. LMFTs and mental health counselors are paid the same way, on assignment.

By Gale Editorial · Updated 2026-09-01. Every figure cited to a dated source. How we write.

What does Medicare pay an LCSW for 90837?

Seventy-five percent of what it pays a clinical psychologist for the same code in your locality, then 80 percent of that, with the patient owing 20 percent. The statute sets clinical social worker services at 80 percent of the lesser of the actual charge or 75 percent of the psychologist's payment amount 1Ref 1Office of the Law Revision Counsel, U.S. House of Representatives (2026).42 U.S.C. §1395l. Payment of benefits.The statutory payment basis: 80 percent of the lesser of the actual charge or 75 percent of the psychologist payment amount, for clinical social worker services under 1395l(a)(1)(F) and for marriage and family therapist and mental health counselor services under (FF); the denominator is the psychologist's fee-schedule amount and the lesser-of clause reads on the billed charge. Not used for any dollar figure.. CMS's March 2026 mental health booklet restates it: you must accept assignment, and it pays 75 percent of the fee-schedule amount for clinical psychologists 2Ref 2Centers for Medicare & Medicaid Services, Medicare Learning Network (2026).Medicare & Mental Health Coverage.CMS's own statement, in the March 2026 booklet, that clinical social workers, marriage and family therapists and mental health counselors must accept assignment and are paid at 75 percent of the PFS amount for clinical psychologists, and that clinical psychologists are paid the full PFS amount..

This page prints no dollar figure for 90837, and the omission is deliberate. The psychologist's amount is worked out separately for each Medicare payment locality, the conversion factor that scales it is reset every calendar year, and CMS reissues the underlying files during the year. A figure copied from any one locality would be wrong for most readers on the day they read it and stale for all of them within twelve months.

What holds everywhere is the rule, the arithmetic and the lookup. The rule is above, the arithmetic takes three lines, and the lookup takes a few minutes in the CMS Physician Fee Schedule Look-Up Tool, which returns pricing through a specific MAC or a specific MAC locality 3Ref 3Centers for Medicare & Medicaid Services (2026).PFS Look-up Tool Overview.How the PFS Look-Up Tool works: pricing for more than 10,000 services, search by a single code, a range or a list, results for a specific MAC or MAC locality, and the per-component RVU times GPCI arithmetic. Not used for any code's amount.. The number you leave with is the one your own MAC prices from.

But read the lesser-of clause before you set a fee. Medicare pays 80 percent of the lesser of your actual charge or the 75 percent figure 1Ref 1Office of the Law Revision Counsel, U.S. House of Representatives (2026).42 U.S.C. §1395l. Payment of benefits.The statutory payment basis: 80 percent of the lesser of the actual charge or 75 percent of the psychologist payment amount, for clinical social worker services under 1395l(a)(1)(F) and for marriage and family therapist and mental health counselor services under (FF); the denominator is the psychologist's fee-schedule amount and the lesser-of clause reads on the billed charge. Not used for any dollar figure., so a charge below the reduced amount lowers your own payment: the program then pays on the charge. Set the billed charge for 90837 at or above the allowed amount for your locality and the clause never applies.

What is the 75 percent a percentage of?

The clinical psychologist's fee-schedule amount for the code in your locality, never your own billed charge. The statute's clause for clinical social workers points to the amount determined for payment of a psychologist 1Ref 1Office of the Law Revision Counsel, U.S. House of Representatives (2026).42 U.S.C. §1395l. Payment of benefits.The statutory payment basis: 80 percent of the lesser of the actual charge or 75 percent of the psychologist payment amount, for clinical social worker services under 1395l(a)(1)(F) and for marriage and family therapist and mental health counselor services under (FF); the denominator is the psychologist's fee-schedule amount and the lesser-of clause reads on the billed charge. Not used for any dollar figure., and CMS's booklet puts clinical psychologists at the full fee-schedule amount and clinical social workers, MFTs and mental health counselors at 75 percent of it 2Ref 2Centers for Medicare & Medicaid Services, Medicare Learning Network (2026).Medicare & Mental Health Coverage.CMS's own statement, in the March 2026 booklet, that clinical social workers, marriage and family therapists and mental health counselors must accept assignment and are paid at 75 percent of the PFS amount for clinical psychologists, and that clinical psychologists are paid the full PFS amount.. So the denominator is the ordinary fee-schedule amount for 90837, and yours is three quarters of it.

That fee-schedule amount is itself a product. Every code carries three relative value units, for work, practice expense and malpractice. Each is multiplied by the geographic practice cost index its locality carries for that component, the three products are summed, and the sum is multiplied by the year's conversion factor 3Ref 3Centers for Medicare & Medicaid Services (2026).PFS Look-up Tool Overview.How the PFS Look-Up Tool works: pricing for more than 10,000 services, search by a single code, a range or a list, results for a specific MAC or MAC locality, and the per-component RVU times GPCI arithmetic. Not used for any code's amount.4Ref 4Centers for Medicare & Medicaid Services (2025).Calendar Year (CY) 2026 Medicare Physician Fee Schedule Final Rule (CMS-1832-F).The two CY 2026 conversion factors, 33.40 dollars nonqualifying APM and 33.57 qualifying, both up from 32.35, and the CY 2026 addition of three add-on G codes comparable to CoCM and BHI when the APCM base code is reported. Not used for a payment amount.. For calendar year 2026 the conversion factor for a practitioner outside a qualifying alternative payment model is 33.40 dollars, up from 32.35, and the qualifying-APM figure is 33.57 dollars 4Ref 4Centers for Medicare & Medicaid Services (2025).Calendar Year (CY) 2026 Medicare Physician Fee Schedule Final Rule (CMS-1832-F).The two CY 2026 conversion factors, 33.40 dollars nonqualifying APM and 33.57 qualifying, both up from 32.35, and the CY 2026 addition of three add-on G codes comparable to CoCM and BHI when the APCM base code is reported. Not used for a payment amount.. A solo therapist uses the lower one.

The reduction belongs to a family of them. Medicare pays several practitioner types a fraction of somebody else's schedule, and the reference amounts are not all the same one:

Practitioner	Medicare basis	Where it is written
Clinical psychologist	The full fee-schedule amount 2Ref 2Centers for Medicare & Medicaid Services, Medicare Learning Network (2026).Medicare & Mental Health Coverage.CMS's own statement, in the March 2026 booklet, that clinical social workers, marriage and family therapists and mental health counselors must accept assignment and are paid at 75 percent of the PFS amount for clinical psychologists, and that clinical psychologists are paid the full PFS amount.	CMS booklet MLN1986542
Nurse practitioner	Up to 85 percent of the physician fee-schedule amount 5Ref 5Office of the Federal Register (2026).42 CFR 414.56 — Payment for nurse practitioners' and clinical nurse specialists' services.Paragraph (c): Medicare allowed amounts for a nurse practitioner's services may not exceed 85 percent of the physician fee schedule amount, used only as the comparison row in the practitioner-basis table.	42 CFR 414.56(c)
Clinical social worker	75 percent of the psychologist's amount 1Ref 1Office of the Law Revision Counsel, U.S. House of Representatives (2026).42 U.S.C. §1395l. Payment of benefits.The statutory payment basis: 80 percent of the lesser of the actual charge or 75 percent of the psychologist payment amount, for clinical social worker services under 1395l(a)(1)(F) and for marriage and family therapist and mental health counselor services under (FF); the denominator is the psychologist's fee-schedule amount and the lesser-of clause reads on the billed charge. Not used for any dollar figure.	42 U.S.C. 1395l(a)(1)(F)
Marriage and family therapist, mental health counselor	75 percent of the psychologist's amount 1Ref 1Office of the Law Revision Counsel, U.S. House of Representatives (2026).42 U.S.C. §1395l. Payment of benefits.The statutory payment basis: 80 percent of the lesser of the actual charge or 75 percent of the psychologist payment amount, for clinical social worker services under 1395l(a)(1)(F) and for marriage and family therapist and mental health counselor services under (FF); the denominator is the psychologist's fee-schedule amount and the lesser-of clause reads on the billed charge. Not used for any dollar figure.	42 U.S.C. 1395l(a)(1)(FF)

The nurse practitioner row is there on purpose. A clinician who has read about the Medicare 85% rule for NPs will expect the psychotherapy reduction to work the same way, and it does: a fixed fraction of a reference schedule, applied when the claim is priced. The fraction is smaller here, and the reference practitioner is a psychologist rather than a physician.

The basis is also a Medicare rule and nothing wider. It is written into the Social Security Act, and it says nothing about what a commercial plan or a state Medicaid program pays a social worker relative to a psychologist. Those rates come from the contract or the state's own fee schedule, and each has to be read on its own.

The arithmetic, with a round number. Call the psychologist's amount for 90837 in your locality 100 dollars, chosen for the multiplication and nothing else. Your allowed amount is 75. Medicare pays 80 percent of that, 60, and the patient owes 15 in coinsurance, after whatever Part B deductible is still outstanding. Bill 70 on the claim and Medicare pays 80 percent of 70 instead, under the lesser-of clause 1Ref 1Office of the Law Revision Counsel, U.S. House of Representatives (2026).42 U.S.C. §1395l. Payment of benefits.The statutory payment basis: 80 percent of the lesser of the actual charge or 75 percent of the psychologist payment amount, for clinical social worker services under 1395l(a)(1)(F) and for marriage and family therapist and mental health counselor services under (FF); the denominator is the psychologist's fee-schedule amount and the lesser-of clause reads on the billed charge. Not used for any dollar figure.. Bill 150 and nothing changes, because the allowed amount stays 75 and accepting assignment means the balance is never the patient's to pay.

How do you look up 90837 for your own locality?

Open the CMS Physician Fee Schedule Look-Up Tool, search 90837, choose your MAC or your MAC locality, read the fee-schedule amount, and multiply it by 0.75. The tool returns pricing and relative value units for more than 10,000 services, and it can be searched for a single code, a range or a list, through a specific MAC or a specific MAC locality 3Ref 3Centers for Medicare & Medicaid Services (2026).PFS Look-up Tool Overview.How the PFS Look-Up Tool works: pricing for more than 10,000 services, search by a single code, a range or a list, results for a specific MAC or MAC locality, and the per-component RVU times GPCI arithmetic. Not used for any code's amount.. A few minutes, no login, and the answer is your locality's.

Pick the year deliberately. A remittance from last December was priced on last year's file, and the conversion factor changed on January 1 4Ref 4Centers for Medicare & Medicaid Services (2025).Calendar Year (CY) 2026 Medicare Physician Fee Schedule Final Rule (CMS-1832-F).The two CY 2026 conversion factors, 33.40 dollars nonqualifying APM and 33.57 qualifying, both up from 32.35, and the CY 2026 addition of three add-on G codes comparable to CoCM and BHI when the APCM base code is reported. Not used for a payment amount..
Search by locality rather than by MAC where the tool offers both. A MAC covers several localities, and each carries its own indexes for the three components 3Ref 3Centers for Medicare & Medicaid Services (2026).PFS Look-up Tool Overview.How the PFS Look-Up Tool works: pricing for more than 10,000 services, search by a single code, a range or a list, results for a specific MAC or MAC locality, and the per-component RVU times GPCI arithmetic. Not used for any code's amount..
Read the non-facility amount for a session in your own office. The relative value file carries facility and non-facility totals for each code 6Ref 6Centers for Medicare & Medicaid Services (2026).RVU26A — 2026 National Physician Fee Schedule Relative Value File January Release.That the January 2026 relative value file carries per-code work, practice-expense and malpractice RVUs, facility and non-facility totals, the conversion factor column and the final CY 2026 GPCIs in Addendum E, and that CMS reissues it quarterly. No RVU value or dollar figure is quoted from it., and the two are priced differently.
Multiply by 0.75. The tool shows the fee-schedule amount, which is the psychologist's, and the reduction to 75 percent is yours to apply 2Ref 2Centers for Medicare & Medicaid Services, Medicare Learning Network (2026).Medicare & Mental Health Coverage.CMS's own statement, in the March 2026 booklet, that clinical social workers, marriage and family therapists and mental health counselors must accept assignment and are paid at 75 percent of the PFS amount for clinical psychologists, and that clinical psychologists are paid the full PFS amount..
Multiply by 0.80 for Medicare's share, and expect to collect the remaining 20 percent from the patient.

Behind the tool sit two files worth knowing by name. The 2026 relative value file, RVU26A, is the January release; it carries each code's work, practice-expense and malpractice units, the conversion factor in a column of its own, and in Addendum E the final 2026 indexes by state and locality 6Ref 6Centers for Medicare & Medicaid Services (2026).RVU26A — 2026 National Physician Fee Schedule Relative Value File January Release.That the January 2026 relative value file carries per-code work, practice-expense and malpractice RVUs, facility and non-facility totals, the conversion factor column and the final CY 2026 GPCIs in Addendum E, and that CMS reissues it quarterly. No RVU value or dollar figure is quoted from it.. CMS replaces it during the year, as RVU26B, C and D 6Ref 6Centers for Medicare & Medicaid Services (2026).RVU26A — 2026 National Physician Fee Schedule Relative Value File January Release.That the January 2026 relative value file carries per-code work, practice-expense and malpractice RVUs, facility and non-facility totals, the conversion factor column and the final CY 2026 GPCIs in Addendum E, and that CMS reissues it quarterly. No RVU value or dollar figure is quoted from it.. The conversion factor comes from the annual final rule, and the 2026 rule also added three add-on G codes comparable to collaborative care and behavioral health integration, payable when the advanced primary care management base code is reported 4Ref 4Centers for Medicare & Medicaid Services (2025).Calendar Year (CY) 2026 Medicare Physician Fee Schedule Final Rule (CMS-1832-F).The two CY 2026 conversion factors, 33.40 dollars nonqualifying APM and 33.57 qualifying, both up from 32.35, and the CY 2026 addition of three add-on G codes comparable to CoCM and BHI when the APCM base code is reported. Not used for a payment amount..

Each of these numbers carries a date. Write the calendar year next to the figure when it goes into your fee schedule, and check it again each January.

Do LMFTs and mental health counselors get the same 75 percent?

Yes. The statute applies the identical basis to marriage and family therapist services and mental health counselor services: 80 percent of the lesser of the actual charge or 75 percent of the psychologist's payment amount 1Ref 1Office of the Law Revision Counsel, U.S. House of Representatives (2026).42 U.S.C. §1395l. Payment of benefits.The statutory payment basis: 80 percent of the lesser of the actual charge or 75 percent of the psychologist payment amount, for clinical social worker services under 1395l(a)(1)(F) and for marriage and family therapist and mental health counselor services under (FF); the denominator is the psychologist's fee-schedule amount and the lesser-of clause reads on the billed charge. Not used for any dollar figure.. CMS's booklet says the same under each practitioner type's own payment heading, with the same accept-assignment condition 2Ref 2Centers for Medicare & Medicaid Services, Medicare Learning Network (2026).Medicare & Mental Health Coverage.CMS's own statement, in the March 2026 booklet, that clinical social workers, marriage and family therapists and mental health counselors must accept assignment and are paid at 75 percent of the PFS amount for clinical psychologists, and that clinical psychologists are paid the full PFS amount.. In a given locality an LCSW, an LMFT and an LPC enrolled as a mental health counselor collect the same allowed amount for 90837.

The two newer categories date from Medicare's 2024 opening. Section 4121 of the Consolidated Appropriations Act, 2023 created the benefit, and CMS's final rule for calendar year 2024 implemented it, with billing permitted from January 1, 2024, consistent with statute 7Ref 7Centers for Medicare & Medicaid Services (2023).Calendar Year (CY) 2024 Medicare Physician Fee Schedule Final Rule.The creation of the MFT and MHC benefit under Section 4121 of the CAA, 2023, billing from January 1, 2024, the addiction and drug and alcohol counselor pathway into the MHC category, and the opening of the HBAI codes to CSWs, MFTs and MHCs. Not used for a current-year rate.. The same rule brought addiction and drug and alcohol counselors in through the mental health counselor category, and opened the health behavior assessment and intervention codes to clinical social workers, MFTs and MHCs 7Ref 7Centers for Medicare & Medicaid Services (2023).Calendar Year (CY) 2024 Medicare Physician Fee Schedule Final Rule.The creation of the MFT and MHC benefit under Section 4121 of the CAA, 2023, billing from January 1, 2024, the addiction and drug and alcohol counselor pathway into the MHC category, and the opening of the HBAI codes to CSWs, MFTs and MHCs. Not used for a current-year rate..

Who qualifies is defined in regulation, and the state titles reach wider than the Medicare label. A mental health counselor for Medicare purposes is licensed or certified by the state as a mental health counselor, a clinical professional counselor or a professional counselor, holds a qualifying master's or doctoral degree, and has at least two years or 3,000 hours of post-degree clinical supervised experience 8Ref 8Office of the Federal Register / Centers for Medicare & Medicaid Services (2023).42 CFR 410.54 — Mental health counselor services.The federal definition of a mental health counselor for Medicare: the qualifying state titles, the master's or doctoral degree, and the post-degree two-years-or-3,000-hours supervised-experience condition.. A clinical social worker holds a master's or doctoral degree in social work, has performed at least two years of supervised clinical social work after the degree, and is licensed or certified by the state 9Ref 9National Archives and Records Administration, Office of the Federal Register (2026).42 CFR § 410.73 Clinical social worker services.The federal definition of a clinical social worker for Medicare (master's or doctoral degree in social work, at least two years of supervised clinical social work, state licensure or certification) and the excluded inpatient, SNF and ESRD-facility settings.. Services to hospital inpatients, skilled nursing facility inpatients and certain dialysis-facility patients sit outside the clinical social worker benefit 9Ref 9National Archives and Records Administration, Office of the Federal Register (2026).42 CFR § 410.73 Clinical social worker services.The federal definition of a clinical social worker for Medicare (master's or doctoral degree in social work, at least two years of supervised clinical social work, state licensure or certification) and the excluded inpatient, SNF and ESRD-facility settings..

Enrollment runs through PECOS or the paper CMS-855I. Because the paper form predates the two specialties, CMS's May 2024 FAQ has an MFT or MHC write the specialty into section 2H, the undefined non-physician practitioner line, until a revised form adds them 10Ref 10Centers for Medicare & Medicaid Services (2024).Marriage and Family Therapists (MFTs) and Mental Health Counselors (MHCs) Provider Enrollment Frequently Asked Questions (FAQs).MFT and MHC enrollment mechanics: PECOS or the paper CMS-855I with the specialty written into section 2H until a revised form adds it, one CMS-855I per state where services are rendered, no application fee, and opt-out as the alternative to enrollment.. A separate CMS-855I is needed for each state where services are rendered, and MFTs and MHCs pay no application fee 10Ref 10Centers for Medicare & Medicaid Services (2024).Marriage and Family Therapists (MFTs) and Mental Health Counselors (MHCs) Provider Enrollment Frequently Asked Questions (FAQs).MFT and MHC enrollment mechanics: PECOS or the paper CMS-855I with the specialty written into section 2H until a revised form adds it, one CMS-855I per state where services are rendered, no application fee, and opt-out as the alternative to enrollment.. The sequence is worked step by step in 855I enrollment for LPCs and LMFTs; the payment basis on this page is what the enrollment buys.

Which psychotherapy code does the session take?

The one whose time band the session falls in, with 90837 reserved for 53 minutes or more. One MAC's billing and coding article, A57520, sets the bands at 16 to 37 minutes for 90832, 38 to 52 minutes for 90834 and 53 or more for 90837, takes the code closest to the actual time, and reports no psychotherapy code at all under 16 minutes 11Ref 11First Coast Service Options, Inc. (A and B MAC, Jurisdiction N), for the Centers for Medicare & Medicaid Services (2025).Billing and Coding: Psychiatric Diagnostic Evaluation and Psychotherapy Services (A57520).One MAC's billing and coding article: the 16-37, 38-52 and 53-or-more minute bands for 90832, 90834 and 90837, no psychotherapy code under 16 minutes, the start-and-stop or total-time documentation requirement, and the codes 90785 accompanies with its own time documentation; presented as First Coast's jurisdiction, illustrative for other MACs..

The article binds First Coast's jurisdiction: Florida, Puerto Rico and the U.S. Virgin Islands 11Ref 11First Coast Service Options, Inc. (A and B MAC, Jurisdiction N), for the Centers for Medicare & Medicaid Services (2025).Billing and Coding: Psychiatric Diagnostic Evaluation and Psychotherapy Services (A57520).One MAC's billing and coding article: the 16-37, 38-52 and 53-or-more minute bands for 90832, 90834 and 90837, no psychotherapy code under 16 minutes, the start-and-stop or total-time documentation requirement, and the codes 90785 accompanies with its own time documentation; presented as First Coast's jurisdiction, illustrative for other MACs.. Other MACs publish their own, and the Medicare Coverage Database is where to find yours.

Minutes of psychotherapy	Code
Under 16	Not reported
16 to 37	90832
38 to 52	90834
53 or more	90837

The same article makes the note's job explicit: start and stop times, or a total time, must be documented for 90832, 90834 and 90837 11Ref 11First Coast Service Options, Inc. (A and B MAC, Jurisdiction N), for the Centers for Medicare & Medicaid Services (2025).Billing and Coding: Psychiatric Diagnostic Evaluation and Psychotherapy Services (A57520).One MAC's billing and coding article: the 16-37, 38-52 and 53-or-more minute bands for 90832, 90834 and 90837, no psychotherapy code under 16 minutes, the start-and-stop or total-time documentation requirement, and the codes 90785 accompanies with its own time documentation; presented as First Coast's jurisdiction, illustrative for other MACs.. Without a time in the record, nothing in the note supports the band. The article also lists the codes 90785 interactive complexity may accompany, 90791, 90792 and the three psychotherapy codes among them, and requires the interactive-complexity time to be documented when the add-on rides on a timed code 11Ref 11First Coast Service Options, Inc. (A and B MAC, Jurisdiction N), for the Centers for Medicare & Medicaid Services (2025).Billing and Coding: Psychiatric Diagnostic Evaluation and Psychotherapy Services (A57520).One MAC's billing and coding article: the 16-37, 38-52 and 53-or-more minute bands for 90832, 90834 and 90837, no psychotherapy code under 16 minutes, the start-and-stop or total-time documentation requirement, and the codes 90785 accompanies with its own time documentation; presented as First Coast's jurisdiction, illustrative for other MACs..

The 75 percent applies at every band. The statute reduces clinical social worker services as a category, so 90832, 90834, 90837 and the diagnostic evaluation 90791 all pay at three quarters of the psychologist's amount for that code 1Ref 1Office of the Law Revision Counsel, U.S. House of Representatives (2026).42 U.S.C. §1395l. Payment of benefits.The statutory payment basis: 80 percent of the lesser of the actual charge or 75 percent of the psychologist payment amount, for clinical social worker services under 1395l(a)(1)(F) and for marriage and family therapist and mental health counselor services under (FF); the denominator is the psychologist's fee-schedule amount and the lesser-of clause reads on the billed charge. Not used for any dollar figure.. What changes between bands is the denominator, since each code carries its own relative value units 6Ref 6Centers for Medicare & Medicaid Services (2026).RVU26A — 2026 National Physician Fee Schedule Relative Value File January Release.That the January 2026 relative value file carries per-code work, practice-expense and malpractice RVUs, facility and non-facility totals, the conversion factor column and the final CY 2026 GPCIs in Addendum E, and that CMS reissues it quarterly. No RVU value or dollar figure is quoted from it..

What does accepting assignment foreclose?

Billing the patient anything beyond the deductible and the 20 percent coinsurance. CMS's condition for clinical social workers, marriage and family therapists and mental health counselors takes one line: you must accept assignment 2Ref 2Centers for Medicare & Medicaid Services, Medicare Learning Network (2026).Medicare & Mental Health Coverage.CMS's own statement, in the March 2026 booklet, that clinical social workers, marriage and family therapists and mental health counselors must accept assignment and are paid at 75 percent of the PFS amount for clinical psychologists, and that clinical psychologists are paid the full PFS amount.. Accepting assignment means the Medicare-approved amount, the 75 percent figure, is payment in full. Medicare sends its 80 percent, the patient owes the rest, and the gap between your fee and the approved amount is written off.

That leaves two positions for a clinician in these categories. Enroll, bill on assignment and take the locality's reduced amount; or opt out of Medicare and see beneficiaries under private contracts, which CMS's enrollment FAQ names as the alternative for MFTs and MHCs 10Ref 10Centers for Medicare & Medicaid Services (2024).Marriage and Family Therapists (MFTs) and Mental Health Counselors (MHCs) Provider Enrollment Frequently Asked Questions (FAQs).MFT and MHC enrollment mechanics: PECOS or the paper CMS-855I with the specialty written into section 2H until a revised form adds it, one CMS-855I per state where services are rendered, no application fee, and opt-out as the alternative to enrollment.. There is no middle position for these three practitioner types.

Which of the two fits depends on the caseload. A practice with a large share of patients over 65 is choosing between a reduced rate and no Medicare revenue at all; a practice with few of them is choosing whether the enrollment is worth maintaining. The arithmetic of opting out mid-career, with a Medicare-heavy caseload already on the books, is its own question, and it turns on numbers only your own ledger holds.

A third path runs through someone else's practice. The 2026 final rule added three add-on G codes comparable to collaborative care management and behavioral health integration, reported alongside the advanced primary care management base code 4Ref 4Centers for Medicare & Medicaid Services (2025).Calendar Year (CY) 2026 Medicare Physician Fee Schedule Final Rule (CMS-1832-F).The two CY 2026 conversion factors, 33.40 dollars nonqualifying APM and 33.57 qualifying, both up from 32.35, and the CY 2026 addition of three add-on G codes comparable to CoCM and BHI when the APCM base code is reported. Not used for a payment amount.. Those are the treating practice's codes, and an LCSW as CoCM care manager is paid by that practice under its own arrangement rather than under the 75 percent basis. It is a different set of rules, worth knowing about before treating the 75 percent as the ceiling on what Medicare-funded work can pay.

Nothing on this page recommends enrolling or opting out. It is the rate, where it is written, and how to read it for your own locality. The election is yours to make, with your accountant if you have one.

Common questions

No figure that is right everywhere. The psychologist's fee-schedule amount for 90837 is priced per Medicare locality through geographic indexes on each RVU component, and the conversion factor that scales it changes every January. Search 90837 for your MAC locality in the CMS PFS Look-Up Tool, take 75 percent of the amount shown, and write the calendar year beside the result so it is not carried into a year it no longer describes.

No. The 75 percent basis is written into the Social Security Act and governs Medicare Part B payment for clinical social worker, marriage and family therapist and mental health counselor services. A commercial plan pays whatever its contract with you says, and a state Medicaid program pays from its own fee schedule. Read each on its own terms rather than assuming the Medicare fraction carries over.

No. CMS requires clinical social workers, marriage and family therapists and mental health counselors to accept assignment, which makes the Medicare-approved amount payment in full. You collect the Part B deductible and the 20 percent coinsurance from the patient, Medicare pays its 80 percent, and the rest of your fee is written off. The alternative to enrolling on those terms is opting out of Medicare altogether.

Yes, once enrolled as a mental health counselor. The federal definition reaches anyone the state licenses as a mental health counselor, clinical professional counselor or professional counselor with the degree and post-degree supervised experience the regulation lists. The statute then pays MHC services on the same basis as clinical social worker services: 80 percent of the lesser of the charge or 75 percent of the psychologist's amount.

Then it is a 90834 under the time bands one MAC's billing and coding article sets out: 38 to 52 minutes for 90834, 53 or more for 90837, choosing the code closest to the actual time. The note has to carry start and stop times or a total time for either code. The 75 percent reduction is the same at both bands; only the fee-schedule amount it is taken from differs.

Most often because the tool shows the full fee-schedule amount and your MAC paid 75 percent of it, then 80 percent of that after the patient's share. Check next that the year matches, that you searched your own locality rather than the MAC-wide or national figure, that you read the non-facility column for an office session, and that any Part B deductible still outstanding was applied first.

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References

1.Office of the Law Revision Counsel, U.S. House of Representatives (2026). 42 U.S.C. §1395l. Payment of benefits. United States Code (prelim), uscode.house.gov. link ✓The statutory payment basis: 80 percent of the lesser of the actual charge or 75 percent of the psychologist payment amount, for clinical social worker services under 1395l(a)(1)(F) and for marriage and family therapist and mental health counselor services under (FF); the denominator is the psychologist's fee-schedule amount and the lesser-of clause reads on the billed charge. Not used for any dollar figure.
2.Centers for Medicare & Medicaid Services, Medicare Learning Network (2026). Medicare & Mental Health Coverage. CMS Medicare Learning Network booklet MLN1986542. link ✓CMS's own statement, in the March 2026 booklet, that clinical social workers, marriage and family therapists and mental health counselors must accept assignment and are paid at 75 percent of the PFS amount for clinical psychologists, and that clinical psychologists are paid the full PFS amount.
3.Centers for Medicare & Medicaid Services (2026). PFS Look-up Tool Overview. CMS.gov, Physician Fee Schedule. link ✓How the PFS Look-Up Tool works: pricing for more than 10,000 services, search by a single code, a range or a list, results for a specific MAC or MAC locality, and the per-component RVU times GPCI arithmetic. Not used for any code's amount.
4.Centers for Medicare & Medicaid Services (2025). Calendar Year (CY) 2026 Medicare Physician Fee Schedule Final Rule (CMS-1832-F). CMS Newsroom fact sheet. link ✓The two CY 2026 conversion factors, 33.40 dollars nonqualifying APM and 33.57 qualifying, both up from 32.35, and the CY 2026 addition of three add-on G codes comparable to CoCM and BHI when the APCM base code is reported. Not used for a payment amount.
5.Office of the Federal Register (2026). 42 CFR 414.56 — Payment for nurse practitioners' and clinical nurse specialists' services. eCFR. link ✓Paragraph (c): Medicare allowed amounts for a nurse practitioner's services may not exceed 85 percent of the physician fee schedule amount, used only as the comparison row in the practitioner-basis table.
6.Centers for Medicare & Medicaid Services (2026). RVU26A — 2026 National Physician Fee Schedule Relative Value File January Release. CMS, PFS Relative Value Files (file rvu26a-updated-12-29-2025.zip, released 12/29/2025). link ✓That the January 2026 relative value file carries per-code work, practice-expense and malpractice RVUs, facility and non-facility totals, the conversion factor column and the final CY 2026 GPCIs in Addendum E, and that CMS reissues it quarterly. No RVU value or dollar figure is quoted from it.
7.Centers for Medicare & Medicaid Services (2023). Calendar Year (CY) 2024 Medicare Physician Fee Schedule Final Rule. CMS Newsroom fact sheet (cms.gov). link ✓The creation of the MFT and MHC benefit under Section 4121 of the CAA, 2023, billing from January 1, 2024, the addiction and drug and alcohol counselor pathway into the MHC category, and the opening of the HBAI codes to CSWs, MFTs and MHCs. Not used for a current-year rate.
8.Office of the Federal Register / Centers for Medicare & Medicaid Services (2023). 42 CFR 410.54 — Mental health counselor services. Electronic Code of Federal Regulations (ecfr.gov). link ✓The federal definition of a mental health counselor for Medicare: the qualifying state titles, the master's or doctoral degree, and the post-degree two-years-or-3,000-hours supervised-experience condition.
9.National Archives and Records Administration, Office of the Federal Register (2026). 42 CFR § 410.73 Clinical social worker services. Electronic Code of Federal Regulations (eCFR), current edition. link ✓The federal definition of a clinical social worker for Medicare (master's or doctoral degree in social work, at least two years of supervised clinical social work, state licensure or certification) and the excluded inpatient, SNF and ESRD-facility settings.
10.Centers for Medicare & Medicaid Services (2024). Marriage and Family Therapists (MFTs) and Mental Health Counselors (MHCs) Provider Enrollment Frequently Asked Questions (FAQs). Centers for Medicare & Medicaid Services (cms.gov). link ✓MFT and MHC enrollment mechanics: PECOS or the paper CMS-855I with the specialty written into section 2H until a revised form adds it, one CMS-855I per state where services are rendered, no application fee, and opt-out as the alternative to enrollment.
11.First Coast Service Options, Inc. (A and B MAC, Jurisdiction N), for the Centers for Medicare & Medicaid Services (2025). Billing and Coding: Psychiatric Diagnostic Evaluation and Psychotherapy Services (A57520). CMS Medicare Coverage Database — Billing and Coding Article. link ✓One MAC's billing and coding article: the 16-37, 38-52 and 53-or-more minute bands for 90832, 90834 and 90837, no psychotherapy code under 16 minutes, the start-and-stop or total-time documentation requirement, and the codes 90785 accompanies with its own time documentation; presented as First Coast's jurisdiction, illustrative for other MACs.

https://www.gale.care/for-providers/pq-medicare-75-percent-lcsw-lmft-mhc · 11 sources. Competitor details are cited to dated public sources and maintained as they change; figures are estimates, not commitments. Synthetic demonstration.

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