What your 90838 actually pays: Medicare's 2026 rate for the longest add-on

The longest psychotherapy add-on covers a full hour of therapy layered onto a medication visit. It shows up in an unexpected place: multi-hour ketamine-assisted psychotherapy sessions, where it gets billed once alongside the medical E/M code even though the visit itself runs far longer than either code describes on its own.

The code, and where it actually shows up

CPT code 90838 is psychotherapy, 60 minutes or more, billed as an add-on to an evaluation and management (E/M) visit. Like 90833 and 90836, it requires a primary E/M code on the same claim and cannot be billed alone. It represents the longest standard psychotherapy block combined with medication management in one appointment.

One place this code shows up consistently: ketamine-assisted psychotherapy. A solo nurse practitioner running this kind of practice typically sees patients for three-hour sessions, and current procedural terminology (CPT) coding has no single code that covers a session that long. The visit gets billed as an E/M code (commonly 99214) plus 90838, capturing the medical supervision and one hour of the psychotherapy component, with the remainder of the extended session, ketamine's dissociative and integration phases, not separately billable to Medicare or most commercial payers under current coding. Some of these practices add a self-pay component to cover the time the CPT code set does not reach.

What Medicare pays in 2026

Medicare pays $136.61 nationally for 90838 in 2026, up from $122.92 in 2025, an increase of 11.1%. The number underneath that move is the Medicare conversion factor, a single dollar multiplier that CMS applies to every code on the physician fee schedule. It fell for five straight years, from a peak of $36.09 in 2020 to $32.35 in 2025, before this year's rule reversed course: $33.40 for 2026, a 3.26% increase. Behavioral health and time-based codes were explicitly exempted from a separate 2.5% efficiency cut applied elsewhere in the same rule. Stacked onto a 2026 99214, a 90838 add-on brings the combined insurance-billable portion of the visit to $272.22.

What commercial payers pay

PayerPrice shows national average commercial rates for 90838 from $123.17 (BCBS/Anthem) to $191.42 (Cigna) as of August 2026, with Cigna paying meaningfully above every other payer including Medicare.

The so-what

• Know what your coding actually covers. If a session runs three hours and the insurance-billable codes cover roughly one, the practice needs a clear, disclosed self-pay structure for the remainder, not an assumption that a bigger E/M code will absorb it.
• Document the full session, not just the billable hour. A note that only covers the portion mapped to a CPT code leaves the rest of a long session clinically undocumented, a real risk if anything happens during the part that was not written down.