Therapists working in family or couples contexts often find themselves in nuanced situations where someone other than the identified client, or “primary patient,” is present, or even the sole participant in a session. Whether you’re speaking to a caregiver, partner, or parent, it’s essential to understand how to navigate these moments clinically, ethically, and within the bounds of documentation and billing requirements.
This guide is here to support you in making informed decisions about sessions that don’t include the primary patient, while preserving clinical integrity and honoring CPT code and billing expectations.
Why This Matters
These types of sessions can be incredibly valuable. They allow you to:
- Gather insights that support the treatment plan.
- Provide education and skills training to caregivers.
- Address relational dynamics that impact the primary patient’s healing.
But they can also raise questions: Is this a collateral contact or a billable session? Which code is appropriate? How do I document and bill this properly?
Step 1: Clarify the Purpose and Boundaries
Start by grounding the session in clinical intent:
- Who is the primary patient? In an insurance-based clinical setting, there are two types of people who may attend sessions:
1. The primary patient – the individual with the diagnosis whose care is being billed.
2. Non-primary attendees – such as parents, caregivers, or partners who may participate in support of the primary patient’s treatment.
All documentation must focus on the primary patient’s clinical needs and reflect how each session supports their progress.
- Why are you meeting without the primary patient? Ensure this session is clearly in service of the primary patient’s specific treatment goals. If not, this is likely not a billable service.
- Is the primary patient aware of this meeting and consents to it? Involving others in a client’s care without the informed consent of the adult client- or the parent/guardian with legal medical decision-making authority for a minor- is both unethical and non-billable. Consent must be obtained before proceeding.
- Is the participant aware of their role? Gather consent from non-primary participants using this consent form.
- Set clear expectations. Explain confidentiality boundaries and what will (or won’t) be shared.
Step 2: Determine the Right Session Type
Use this framework to guide your coding and documentation:
1. Collateral Contact (Non-Billable)
Information gathering only.
Example: A teacher or parent reports classroom behavior changes. The partner of the primary patient reports continued relational discord in a phone call with the therapist. No intervention is provided in either situation.
- Requires a signed Release of Information.
- Document with a blank note in the primary patient’s record.
2. 90846 – Family Therapy Without the Patient Present (Billable)
Therapeutic interventions focused on improving the primary patient’s mental health.
Examples of therapeutic interventions:
- Teaching parents grounding techniques.
- Psychoeducation on panic attack responses.
- Role-playing communication strategies.
This session must include structured, therapeutic work with clear therapeutic interventions that align with the primary patient’s treatment plan.
3. 90837 – Individual Psychotherapy (for Non-Primary Patient)
Therapy for the person in the room, not the primary patient.
Example: A parent explores their own anxiety. The romantic partner of the primary patient is exploring their experience of infidelity initiated by the primary patient.
- This is a separate clinical case- the person must be registered as a patient and billed under their own insurance.
- Do not document this in the primary patient’s chart.
- This is not billable under the primary patient’s chart.
Documentation Tips
- Be specific: Who was there, what interventions you used, and how it ties to the client’s goals.
- Stay treatment-aligned: Keep the focus on the primary patient. Documentation must clearly show how every contact supports the client’s treatment plan.
- Respect boundaries: Don’t drift into therapy for the parent unless they’re registered separately.
- Avoid double billing (e.g., seeing the client and a family member separately in one day). Only one service is billable per day.
Now that we’ve established the basics, let’s bring this into the complex reality of clinical work, where things may not be as straightforward.
Choosing the Right CPT Code for Complex Clinical Situations
Therapy with minors often includes time with caregivers or family members. Use your clinical judgment to determine the most appropriate billing code, based on who was present, for how long, and what the clinical focus was. Here's a quick guide to help you decide:
| Code | When to Use | Example | Important Considerations |
| 90834(Individual Therapy, 38–52 min) | The client is present for most of the session, and any caregiver involvement is brief. | 45 minutes of billable time with the minor client; 15 minutes updating the parent on progress | The focus remains on 1:1 therapeutic work with the client. |
| 90837(Individual Therapy, 53+ min) | The session is longer (53+ minutes) and includes both individual and joint time, but the primary clinical focus is still on the minor. | 54 minutes with the minor; 30 minutes with both parent and client. | - |
| 90846(Family Therapy Without the Client Present) | The parent, caregiver, or non-primary adult patient is seen alone for most of the session, and the discussion is directly tied to providing interventions that support patient's treatment plan. | 10 minutes with the minor; 45 minutes with the parent receiving psychoeducation about autism and some information about how to intervene with escalated behavior. | If the time with the caregiver isn't clearly connected to interventions that support the child’s treatment plan, this may not be billable. Collateral contact (e.g. providing updates about progress) or soliciting information about the client is not billable at Rula. |
| 90847(Family Therapy With the Client Present) | The session includes both the child and parent engaging in structured, goal-oriented interventions. | 29 minutes with the minor; 30 minutes with both doing therapeutic work. OR 30 minutes 1:1 with the client; 30 minutes joint therapeutic work with parent and client. | Use when more than half of the session includes active therapeutic interventions involving both the client and a family member. |
| Not Billable | The session does not meet time requirements or lacks documentation connecting the conversation to the treatment plan. | 15 minutes with the client (with parent present); client leaves due to distress; therapist speaks with parent for 45 minutes, but documentation does not clarify clinical purpose. | For billing to be appropriate, always document how any caregiver involvement results in interventions gained that support the client’s treatment goals. |
Tip: When in doubt, document clearly and focus on how each part of the session served the client’s treatment plan. Ethical, accurate billing starts with strong clinical rationale and clear documentation.
Example: Tying It All Together
Patient A is a teen with a diagnosis of GAD:
Here are documentation examples from circumstances that may involve this client and their loved ones:
- Collateral Contact Documentation Example:
“Spoke with primary patient’s parent via phone to gather information on classroom behavior. Parent reported that patient’s teacher reported increased fidgeting and difficulty focusing. No therapeutic interventions were provided. Information will be reviewed with the primary patient and parent in the next session to develop a plan for intervention.” - 90846 Session Documentation Example:
“Met with primary patient’s mother to provide psychoeducation on how to support the patient’s coping strategies for managing panic attacks. Reviewed grounding techniques and role-played a supportive response. Mother verbalized understanding and commitment to implementing strategies. This session aligns with the primary patient’s treatment goal of reducing panic symptoms in relational contexts.”
Example treatment plan:
1. Goal: “Get Mom and Dad to actually listen to me”
Clinical Goal: Improve Communication Between Patient A and Their Family- “Over the next 12 weeks, Patient A’s will improve communication by using active listening and "I" statements in at least 80% of their interactions with family, as tracked through a weekly communication log, with bi-weekly 90846 sessions to model and review these techniques.
Mother and Father of Patient agree to also use active listening and I statements in their interactions with Patient A”
Example Documentation for 90846 Session:
“Met with Patient A’s family to discuss the importance of active listening and ‘I’ statements in reducing communication barriers. Practiced techniques through role-playing. Family members expressed a commitment to using these strategies in their interactions with Patient A. Follow-up in 2 weeks to assess progress.”
2. Goal: “Not shut down when I’m anxious”
Clinical Goal: Increase Family Support in Managing Patient A’s Anxiety-> “Patient A will use her 5 favorite grounding skills in 90% of anxiety episodes, as tracked through her log. Patient A’s family will apply de-escalation and grounding techniques in 90% of anxiety episodes when they are present, as tracked through a support log, with progress reviewed every 2 weeks in 90846 sessions, and consistent use demonstrated after 12 weeks.”
Example Documentation for 90846 Session:
“Met with Patient A’s family to teach de-escalation techniques, including deep breathing and grounding exercises. Family members practiced these techniques through role-play and reported feeling more confident in supporting Patient A. Progress will be reviewed in 2 weeks with the family’s log of anxiety episodes.”
3. Goal: “I just want to feel understood”
Clinical Goal: Strengthen Family’s Understanding of Patient A’s Treatment Plan and Coping Strategies- > “By next week, Patient A will present her treatment plan to her family. For the weeks after and by the end of 12 weeks, she will give weekly progress updates to her family and will ask her parents for feedback.
By the end of 12 weeks, Patient A’s family will demonstrate a comprehensive understanding of Patient A’s treatment plan, including at least 80% of key coping strategies, by attending bi-weekly 90846 sessions and integrating these strategies into daily interactions.”
Example Documentation for 90846 Session:
“Reviewed Patient A’s treatment plan with the family, discussing specific coping strategies such as grounding exercises and cognitive reframing. Family members demonstrated understanding by asking relevant questions and expressing how they will integrate these strategies into their daily routines. Follow-up in 2 weeks to continue education.”
Quick Guide:
- Is someone other than the primary patient getting therapy for themselves? → not billable under the primary patient’s chart
- Is this contact therapeutic and tied to the primary patient’s treatment plan? → 90846
- Is it just gathering info or offering general support? → Collateral contact (non-billable)
These sessions can be powerful when used intentionally. Keep your documentation clear, your interventions focused, and always connect the work back to the primary patient’s treatment plan.
We understand that billing questions can come up, and you're not alone. Our Quality team is here to support you! If you’re unsure which CPT code best fits your session, feel free to reach out to us at quality@rula.com- we’re happy to help.
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