MedicaidBilling CodesHigh impact
[Ohio] Evaluation and Management (E/M) and Psychotherapy Add-On Billing Policy
CareSource·OH · Psychiatry, Family Medicine, Internal Medicine +2 more·Coding
Effective date
Sep 1, 2026
We identified it
Jul 18, 2026
Summary
CareSource Ohio Medicaid is implementing strict concurrent billing restrictions on psychotherapy add-on codes (90833, 90836, 90838) with high-level E/M services (99204, 99205, 99214, 99215). When billed together on the same date by the same provider, psychotherapy add-ons will be denied and only the E/M will be reimbursed. Providers must now document separate start/stop times, non-overlapping clinical effort, and ensure E/M levels are based on medical decision-making rather than time when billing these combinations.
Action Required
By August 31, 2026: (1) Billing team must update billing system to flag and prevent automatic submission of claims combining psychotherapy add-on codes (90833, 90836, 90838) with E/M codes (99204, 99205, 99214, 99215) on the same date/provider TIN for CareSource Ohio Medicaid members without documented approval. (2) Providers must begin documenting start and stop times for both E/M and psychotherapy services on all encounters where these codes may be used together. (3) Providers must document that psychotherapy and E/M services are substantially and independently identifiable with no overlapping time or clinical effort. (4) Providers must base E/M level selection on medical decision-making complexity alone, not total encounter time, when add-on psychotherapy is billed. (5) Front desk and clinical staff must be trained that prolonged services codes cannot be reported with these psychotherapy add-on combinations. (6) Update encounter templates/EMR to require separate documentation of psychotherapy interventions (symptom reduction, behavior modification, functional support) distinct from E/M medical decision-making. Failure to comply will result in claim denials for the psychotherapy add-on component and potential audit/compliance issues.