The 90837 downcode — where a payer reduces your 60-minute psychotherapy claim to a 90834 (45 minutes) — is the single most expensive habit in mental health billing. Most practices accept it as normal. It is not.
What each payer actually requires
Every payer defines “documented time” differently for the 53-minute threshold that separates a 90837 from a 90834. Here is what we see most often:
Medicare
Medicare follows CMS guidelines: the time threshold is 53 minutes of face-to-face psychotherapy. The documentation must support the full 60 minutes. If the note shows 52 minutes of face-to-face time, the 90834 is correct. If it shows 53 or more, the 90837 stands.
The catch: Medicare counts only face-to-face time. Brief interruptions (answering a phone, a patient stepping out) do not count, but extended breaks do.
UnitedHealthcare
UHC uses a 50-minute threshold for the 90837, which is more generous than Medicare. However, they require specific documentation elements that Medicare does not:
- Start and end times must be documented
- The note must describe the modality used
- Treatment plan review must appear in the session note if applicable
Aetna
Aetna follows the 53-minute threshold but is stricter about what constitutes a “completed” session. If the note is missing a treatment plan update or a diagnosis review, they will downcode regardless of time.
Cigna
Cigna uses the 50-minute threshold but requires that the session note include a clear statement of medical necessity for the 90837 specifically.
The appeal language that works
When a 90837 is downcoded, the appeal should include:
- The specific payer’s time threshold (not a generic “60 minutes”)
- The documented face-to-face time from the session note
- A reference to the payer’s own published policy on 90837 documentation requirements
We check each payer’s current policy before drafting the appeal. Payer policies change quarterly, and an appeal written against an outdated policy is a waste of everyone’s time.
What we do differently
When we onboard a mental health practice, the first thing we audit is the 90837 documentation pattern. We check:
- Whether session notes consistently document time at or just below the threshold
- Whether the EHR is capturing start and end times in a format the payer accepts
- Whether treatment plan updates are appearing in the session notes
Most downcodes are preventable with documentation changes that take less than a minute per session.
Last verified: August 2026. Payer policies are subject to change — contact your payer representative or check the payer’s provider portal for current requirements.
