Private Pay for Couples Therapy: Is it Worth it?
When couples begin looking for therapy, one of the first questions that comes up is: “Do you take insurance?” And for good reason! Insurance can seem like the most straightforward way to access mental health care. But when it comes to couples therapy, and particularly specialized relationship work, private pay often offers more than meets the eye. Here’s what many couples don’t realize: true couples counseling, where the relationship itself is the client, and no one person is diagnosed with a mental health condition, is almost never covered by insurance. In fact, the structure of insurance billing isn’t designed for relationship-focused work at all. While some relationship-focused sessions may be partially reimbursed when linked to one partner's diagnosis, this is not considered true couples therapy and comes with limitations
If you’ve ever wondered whether private pay therapy is worth the investment for you and your partner, this post is here to help clarify the “why” behind it and why so many couples ultimately choose this path.
First, What Is Private Pay Therapy?
Private pay therapy means you pay out of pocket for sessions, rather than using insurance. Some therapists do not work with insurance at all, while others offer both options depending on the service.
In couples work, private pay is often the norm, not the exception, and here’s why that actually works in your favor.
What’s the Difference Between Couples Counseling and a Joint Therapy Session?
Here’s where the confusion starts. Insurance plans may cover a code called 90847: a “conjoint psychotherapy session with the identified patient present.” But this is not the same thing as couples counseling.
90847 (Insurance-Covered Session):
One person is the official patient with a diagnosis
The partner joins to support that individual’s treatment
Documentation goes into the individual’s medical record
Focus is on that person's mental health needs
Time-limited, medically necessary
True Couples Counseling (Private Pay):
The relationship is the client, not either individual, meaning it is equal
Sessions focus on dynamics like communication, conflict, trust, emotional connection, or infidelity
In couples therapy, the record reflects both partners, and neither is considered the sole client. In most cases, both partners must consent to releasing the record, but privacy laws vary by state
Not billable to insurance because there is no diagnosis to either person
In these cases, the therapist may use Z63.0: “Relationship distress with spouse or intimate partner” as a clinical code. This is the most accurate way to document that the therapy is focused on relational conflict, not individual pathology. This distinction is important not just for billing, but also for the ethics, confidentiality, and goals of treatment.
What is Z63.0 and Why Doesn’t Insurance Cover it?
When doing true couples counseling, therapists often use the ICD-10 code Z63.0, which stands for:
“Relationship distress with spouse or intimate partner”
This code is often used in true couples counseling when the focus is on the health of the relationship, not on diagnosing a mental disorder in either partner. Z63.0 is not a mental health disorder: it’s a relational issue code. It’s used to document that therapy is addressing relationship distress, not an individual’s mental illness. Because of that, most insurers do not consider it medically necessary and therefore do not usually cover services tied to it
Most insurance companies do not cover treatment based on Z-codes, because:
They don’t view relationship issues as a medical necessity
Z-codes are considered “V-codes” or “non-billable” codes
There’s no reimbursable procedure code tied directly to treating the relationship
While Z63.0 is clinically appropriate for many couples seeking therapy, it is typically not reimbursable by most insurance plans, since Z-codes are considered non-medical or non-billable under most coverage policies.
Can You Submit 90847 with Z63.0?
Technically, yes, a therapist can submit 90847 with a Z63.0 diagnosis (you need both a CPT code and a diagnosis to bill insurance).
However, in most cases, this will not be covered, because Z63.0 is not considered medically necessary treatment by most insurers.
Important Tip: If you call your insurance to ask “Is couples counseling covered?”, a representative may say yes, because 90847 is a valid, billable code.
But they may not tell you that coverage depends entirely on the diagnosis attached to the claim. That’s why it’s essential to ask specifically:
“Do you cover sessions billed under code 90847 with diagnosis code Z63.0?”
That’s the only way to know whether your relationship-focused therapy would actually be reimbursed. Even if your therapist is out-of-network and provides a superbill, sessions billed with Z63.0 are still unlikely to be reimbursed, since most plans don’t accept Z-codes as medically necessary treatment.
So Why Do Some Therapists Still Offer Couples Counseling Through Insurance?
You may come across therapists who do offer what appears to be couples counseling through insurance, and there are a few reasons for this:
They’re offering supportive conjoint therapy under a diagnosis for one partner, using 90847, and framing the work accordingly
They prioritize accessibility, aiming to reduce cost barriers for clients
They may not be aware of the legal or ethical complexities, or have never been audited
They choose to assume the risk, knowingly or not, of billing insurance for relationship work that isn’t technically covered
In some cases, they’re using creative workarounds to support couples, but these may not hold up in the event of an audit or legal situation
This isn’t meant to criticize, as every therapist makes their own clinical and business decisions. But it’s important for clients to understand that when insurance is used, there are strings attached from documentation and diagnosis, to who legally “owns” the record, to how treatment is structured. This is why it’s so important to be an informed consumer: ask your provider specific questions, and make sure you understand what you’re being billed for and why
Why Private Pay Makes Sense for Couples
1. You're Getting the Right Type of Care
Using insurance for couples therapy usually means you're not actually getting couples therapy, you're getting individual therapy with the partner sitting in. That may help short term, but it won't address the deeper relationship patterns, especially if you're navigating things like:
Escalating conflict
Infidelity
Communication breakdowns
Emotional withdrawal
With private pay, you get therapy that’s built around the relationship itself, not limited by insurance definitions or documentation rules.
2. Sessions Are Longer, Deeper, and More Flexible
Most insurance-covered sessions are 45–55 minutes and that’s often not enough for complex relationship work. 90847 can be billed for sessions that last 26 minutes or more. Insurance reimbursement typically doesn’t increase after that threshold, so whether your session is 26 minutes or 55 minutes, the payment to the therapist is often the same, which can limit the time available for deeper relationship work.
At Bloom Within Counseling, couples sessions are 90 minutes, using the Gottman Method, a research-based approach to understanding and improving relationship dynamics. Longer sessions allow for:
Deeper emotional processing
Structured interventions with time for follow-up
Space to navigate difficult conversations safely
You’re not rushed, and you don’t have to fit meaningful work into an insurance-imposed time box. There are two of you after all!
3. Full Confidentiality and Shared Ownership
With private pay couples therapy:
In private pay couples therapy, the clinical record reflects both partners, and while neither is labeled the ‘patient,’ laws around record access and ownership vary by state. In most cases, both partners must consent to releasing the record.
No one is labeled the “patient” or pathologized
You avoid diagnoses entering your medical history
You're more protected in legal or court-related scenarios
This is especially important if you’re navigating high-conflict dynamics, custody concerns, or if either partner has hesitation about therapy being part of their permanent health record.
4. You Choose the Therapist Based on Fit, Not Network
When you pay out of pocket, you’re not limited to in-network therapists. That means you can choose someone who:
Specializes in couples and relationship therapy
Has advanced training (like the Gottman Method)
Offers structure, clarity, and evidence-based tools, not just open-ended talk therapy
This matters when your relationship is in distress. You want someone who knows how to help both of you, not just treat one person.
So… Is It Worth the Cost?
It depends on what you’re hoping to get out of therapy. If you're looking for long-lasting change, better communication, healing from past wounds, and practical tools you can actually use, then private pay therapy is not just a cost, it’s an investment.
In many ways, it’s preventative care for your relationship. Working with a skilled therapist now can reduce long-term stress, resentment, and even the emotional or financial costs of separation or divorce down the road.
The Bottom Line
Private pay therapy gives couples:
The right type of treatment for their needs
The freedom to work deeply and meaningfully
The protection of confidentiality and shared ownership
The expertise of a relationship specialist
If you're ready to invest in your relationship with intention, clarity, and support, private pay therapy may be the path that truly fits.
Interested in Starting Couples Therapy?
I offer 90-minute sessions for couples using the Gottman Method, a structured, research-based model that focuses on communication, conflict resolution, emotional connection, and rebuilding trust. I provide virtual sessions covering Tennessee statewide, including couples counseling for Nashville, Memphis, Knoxville, to Chattanooga, and more.
Insurance is not accepted for couples therapy, but many couples find the investment is well worth the clarity and progress they gain.
Want to learn more or schedule a session? Click here to learn more about couples counseling and to schedule a session.
