Guide

99214 + 90833 vs 90837 for a PMHNP: Pay and Note Requirements

Summary

On the CY 2026 Medicare fee schedule, a 99214 billed with the 90833 psychotherapy add-on pays a PMHNP more than a standalone 90837, because the pair totals 6.50 national non-facility RVUs against 5.00 for the hour of psychotherapy alone. The 85 percent nurse practitioner reduction applies to each service, so it lowers both routes and changes neither's rank. The two routes carry different clock and documentation requirements.

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

Which route pays more on the Medicare fee schedule?

The pair pays more. In the CY 2026 physician fee schedule file, 99214 carries 4.06 total non-facility RVUs and the 90833 add-on carries 2.44, for 6.50 together, while a standalone 90837 carries 5.00 1. That is a gap of 1.50 RVUs, or 30 percent on national values, before any geographic adjustment and before the nurse practitioner reduction.

Turning RVUs into money takes one more step. Medicare multiplies total RVUs by a conversion factor and applies geographic practice cost indices on top, so a national figure is always a figure before locality 2. CY 2026 finalized two conversion factors, $33.57 for qualifying APM participants and $33.40 for practitioners who are not, both up from $32.35 the year before 2. The table runs the arithmetic at the nonqualifying rate the fee schedule file itself carries, 33.4009 1.

CodeWork RVUsTotal non-facility RVUsCY 2026 national arithmetic
992141.924.06$135.61
90833, add-on1.712.44$81.50
99214 with 908333.636.50$217.11
908373.785.00$167.00

Those dollars are arithmetic performed on published inputs rather than a rate CMS prints anywhere, and they are national, CY 2026, and unadjusted. Your own allowed amount moves with your locality's indices and with whichever quarterly release of the relative value file is in force when the claim is processed.

90833 also carries the global indicator ZZZ, the add-on code marker, so it is reported alongside a primary service and has no life of its own 1.

Does the 85 percent nurse practitioner cap change the answer?

No. Medicare allowed amounts for a nurse practitioner's services may not exceed 85 percent of the physician fee schedule amount for the service 3, and that cap lands per service. It applies to the E/M, to the add-on and to the standalone psychotherapy code alike, so it scales both routes by the same factor and leaves the ranking exactly where it was.

Run it through and the pair comes out at $184.54 against $141.95 for the standalone hour, a gap of $42.59 on the same national CY 2026 inputs. The proportion does not move at all: still 30 percent, because a common multiplier cannot change a ratio.

CMS states the rule as payment at 80 percent of the lesser of the actual charge or 85 percent of the amount a physician gets under the fee schedule 4, so the 85 percent step sets the allowed amount and the 80 percent step splits it between the program and patient coinsurance. When someone says medicare pays an np 85%, the 85 percent is the allowed-amount step, and the deposit is 80 percent of that.

What each route demands of the clock

Different amounts of psychotherapy time, and the gap between them is wide. One Medicare contractor publishes the expectation plainly: choose the code closest to the actual psychotherapy time, meaning 16 to 37 minutes for 90832 and 90833, 38 to 52 minutes for 90834 and 90836, and 53 or more minutes for 90837 and 90838, with psychotherapy of less than 16 minutes not reported at all 5.

That article binds First Coast Service Options' jurisdiction, which is Florida, Puerto Rico and the U.S. Virgin Islands, and its current revision took effect January 1, 2025 5. Other contractors publish parallel articles for their own jurisdictions. The same ladder of 90832, 90834, 90837 is billed everywhere, but the document governing your claim is your own MAC's.

Side by side, the operational point is arithmetic: the higher-paying route asks for as little as 16 minutes of psychotherapy, roughly a third of what the standalone hour demands. But it asks for a separately identifiable E/M as well, and that E/M has to be genuinely there.

Documenting two clocks in one visit

The psychotherapy minutes and the E/M work are documented as separate services inside one note. The same contractor article expects the record to carry start and stop times or the total time devoted to psychotherapy, states that psychotherapy total time does not include the E/M time, and treats the two as separately identifiable services when one practitioner performs both 5.

In practice a 45-minute visit does not split itself after the fact. Write the psychotherapy span as its own line with its own start and stop, and let the medication review, the interval history, the risk assessment and the plan stand as the E/M on their own merits. A note recording 45 minutes and nothing further supports one code at most.

The standalone route asks less of the note and more of the calendar. One span, 53 minutes or longer, documented as psychotherapy 5, with no second service to keep apart from it.

How the E/M half gets leveled

By medical decision making or by total time, at the coder's choice. The AMA's E/M material states that an office visit level is selected on medical decision making or on time, and that time here means minimum time, the total physician or qualified health care professional time on the date of service 6. History and exam stopped setting the level under the same revisions 6.

The time route is largely closed to you inside this pairing. Minutes carved out and counted against 90833 are not available to level the E/M as well, since the contractor article puts psychotherapy time outside the E/M time 5. So the E/M half of the pair is normally leveled on medical decision making, which is the same fork behind every 99213 vs 99214 argument in a medication-management practice: how many problems were addressed and in what state, what data was reviewed, and what risk the management carried.

A standalone 90837 has no E/M half to level. It is one service with one clock and one set of documentation expectations, and the coding question ends there.

What the national comparison does not settle

Everything about a payer that is not Medicare. The RVU comparison above is a fact about the Medicare physician fee schedule and it holds only there. Commercial and managed-care fee schedules set their own relativities and their own nurse practitioner differentials, and the federal file says nothing about what any of them pays for either route.

Three things move underneath the figures even within Medicare. The conversion factor resets annually, and CY 2026 carries two of them depending on APM status 2. The relative value file is reissued during the year, so the values above are the July 1, 2026 release 1. Geographic practice cost indices then apply on top, which is why one code pays differently in two localities 2.

Utilization review is a further variable, and it lives in none of the documents above. A plan that scrutinizes the longest psychotherapy band states so in its own policy manual. Read your contract's psychotherapy policy, including how it treats downcoding from 90837 to 90834, before building a schedule around the code; that is ordinary diligence. The Medicare arithmetic answers a narrower question: which route is worth more when both are paid as filed.

The code follows the service delivered, and that order does not reverse. A visit where 20 minutes of psychotherapy sits beside genuine medication management is a 99214 with 90833, and it happens to pay more. An hour of psychotherapy with no separately identifiable E/M is a 90837, whatever the fee schedule says about the alternative. Where a template could be built either way in good faith, that is a practice-design decision for you and whoever handles your billing, and the arithmetic here is one input to it.

Common questions

On the CY 2026 Medicare physician fee schedule, nationally, yes: 6.50 total non-facility RVUs for the pair against 5.00 for the standalone hour. Locality indices and the 85 percent nurse practitioner reduction scale both routes together, so the ranking survives them. A commercial fee schedule with its own relativities can order them differently, so check the schedule that governs the claim.

One Medicare contractor publishes 16 to 37 minutes as the band for 90832 and 90833, with psychotherapy of less than 16 minutes not reported at all, and 53 or more minutes for 90837 and 90838. That article governs Florida, Puerto Rico and the U.S. Virgin Islands. Other contractors publish parallel articles, so confirm the expectation your own MAC prints.

Yes. The cap runs on allowed amounts for a nurse practitioner's services per service, so it lands on the E/M, on the add-on and on the standalone psychotherapy code alike. Because it is the same multiplier applied to both routes, it lowers both totals and leaves the ratio between them untouched. Medicare then pays 80 percent of the reduced allowed amount, with the balance as patient coinsurance.

No. The contractor article states that psychotherapy total time does not include the E/M time, and expects start and stop times or total psychotherapy time in the record. That is why the E/M half of the pair is usually leveled on medical decision making: minutes already counted against the psychotherapy add-on are no longer available to support a time-based E/M level.

No. They are arithmetic on published national inputs, total RVUs multiplied by the CY 2026 conversion factor and then reduced to 85 percent for a nurse practitioner. Geographic practice cost indices adjust every locality, the relative value file is reissued during the year, and the conversion factor resets annually. Run your own codes through the Medicare physician fee schedule look-up tool for a locality-specific figure.

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References

  1. 1.Centers for Medicare & Medicaid Services (2026). Indicators for 2026 (Medicare Physician Fee Schedule payment file, July 1, 2026 release). CMS Physician Fee Schedule Look-Up Tool data (pfs.data.cms.gov). link ✓The CY 2026 per-code RVU values used in the comparison table: 1.92 work and 4.06 total non-facility RVUs for 99214, 1.71 and 2.44 for 90833, 3.78 and 5.00 for 90837, the ZZZ add-on global indicator on 90833, the 33.4009 nonqualifying conversion factor the file carries, and the fact that these are the July 1, 2026 release of a file CMS reissues during the year.
  2. 2.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 CY 2026 conversion factors ($33.57 qualifying APM, $33.40 nonqualifying, both up from $32.35), and the payment mechanic that RVUs become rates through a conversion factor with geographic practice cost indices applied on top.
  3. 3.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 for the service, which is the per-service basis for applying the same reduction to the E/M, the add-on and the standalone psychotherapy code.
  4. 4.Centers for Medicare & Medicaid Services (2025). Medicare and Mental Health Coverage. CMS Medicare Learning Network (MLN1986542). link ✓CMS's statement of the nurse practitioner payment formula as 80 percent of the lesser of the actual charge or 85 percent of the amount a physician gets under the physician fee schedule, which separates the allowed-amount step from the amount Medicare deposits.
  5. 5.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 published psychotherapy time bands (16 to 37 minutes for 90832 and 90833, 38 to 52 for 90834 and 90836, 53 or more for 90837 and 90838, nothing reported under 16 minutes), its requirement to document start and stop times or total psychotherapy time, its statement that psychotherapy total time excludes the E/M time, and the separately-identifiable-services expectation, attributed to First Coast's jurisdiction with the January 1, 2025 revision date.
  6. 6.American Medical Association (2023). CPT evaluation and management (E/M) revisions. American Medical Association (AMA). link ✓The AMA's statement that an office visit E/M level is selected on medical decision making or on total time, that history and exam no longer set the level, and that E/M time means minimum time, the total physician or qualified health care professional time on the date of service.

https://www.gale.care/for-providers/pq-pmhnp-99214-90833-vs-90837 · 6 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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