PTSD uses three ICD-10 codes: F43.10 (unspecified), F43.11 (acute—3 days to 1 month), F43.12 (chronic—1+ months). Most treatment claims bill F43.12. Treatment modalities use standard CPT codes: 90837 (individual therapy, 60 min), 90853 (group therapy, 90+ min), or E/M codes for medication management (99213-99215). Evidence-based treatments—Prolonged Exposure, Cognitive Processing Therapy, EMDR—all bill using these same codes. The treatment modality is documented in the clinical note, not reflected in the CPT code. VA claims follow a different pathway with separate authorization processes.
Choose F43.10, F43.11, or F43.12 based on symptom duration and clarity of onset. F43.11 (acute) applies when the trauma occurred within 1 month; F43.12 (chronic) for longer durations. If onset timing is ambiguous, use F43.10. Bill individual psychotherapy as 90837 (52-60 min) for Prolonged Exposure, CPT, EMDR, or standard talk therapy. Bill group PTSD treatment as 90853 per participant. For medication management (e.g., sertraline for PTSD), use E/M codes 99213-99215. Do not bill both therapy and E/M on the same day. Include the PCL-5 score (Primary Care PTSD Screen) or other validated PTSD measure in each visit.
Most payers cover PTSD treatment when documented with the diagnosis F43.12 and baseline PTSD severity assessment (PCL-5 score 33+). Prior auth is often required; submit documentation of the trauma history, onset date, current symptoms, and treatment plan (typically 16-20 individual sessions for Prolonged Exposure). Some plans limit therapy to 20-30 sessions per year; others offer higher limits for evidence-based treatments. VA covers unlimited sessions for service-connected PTSD. Always verify coverage before intake. Denials often cite insufficient documentation of trauma history or missing PCL-5 baseline.
Do not bundle PTSD therapy and medication E/M on the same day. If a patient has both therapy and med management, schedule on different days or use modifier 25 on the E/M to indicate a distinct service. When PTSD is the primary diagnosis and treated with therapy, do not add secondary mental health diagnoses unless they are comorbidities requiring separate treatment (e.g., F43.12 + F41.1 for comorbid anxiety). Use one primary code per billing cycle. Add-on codes (90838 for additional 30 min of therapy) are allowed if sessions exceed 60 minutes.
Document the trauma type, onset date, and current PTSD symptoms (re-experiencing, avoidance, negative mood, hyperarousal). Record PCL-5 baseline score (goal is 50-point reduction over treatment). Note the treatment modality (Prolonged Exposure, CPT, EMDR, medication, group). For Prolonged Exposure, document the trauma narrative completed and hierarchy of avoided situations. For CPT, record the impact statement and cognitive work. Update PCL-5 regularly (every 4-8 weeks). Track comorbidities (depression, substance use) and functional impact. Include the treatment plan: expected session frequency, modality, and target symptom reduction.
A score of 33+ indicates probable PTSD and justifies treatment billing. However, many payers accept scores of 20+. Always include the baseline PCL-5 in prior auth requests. Track the score throughout treatment to demonstrate progress—payers review treatment efficacy. A patient with a score of 15 may not qualify for continued therapy without clinical justification.
Yes. Prolonged Exposure via telehealth (video with sound) is approved by most payers and VA. Use modifier 95 for synchronous audio-video. In-person delivery is standard, but telehealth is effective. Ensure HIPAA-compliant platform and document patient consent for telehealth.
If the patient is a VA beneficiary with service-connected PTSD, bill the VA directly (requires VA credentialing). If the patient is active duty, file through TRICARE (requires different network status). If the patient is a civilian receiving treatment, use standard commercial insurance billing with F43.12. The payer type determines billing rules, not service history.
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