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Psychotherapy Documentation Tips From an Auditor

Psychotherapy Documentation Tips From an Auditor

Know what auditors want to see in documentation in support of mental health claims.

As a solo practitioner providing mental health counseling to adults, families, and couples, I understood the value of “best practice” documentation. Now, as an auditor, I see insufficient documentation when claims are compared to submitted medical records or progress notes. Many providers utilize various electronic health record (EHR) software to efficiently document patient notes, and some practitioners still rely on handwritten notes. Both methods are considered sufficient if the documentation supports the CPT® codes billed. Here’s how to ensure it does.

Know the Guidelines

State statutes vary on guidelines about privileged information related to psychotherapy notes and progress notes. For the purposes of insurance reimbursement, progress notes are submitted for review as requested by payers or internal/external auditors. The Centers for Medicare & Medicaid Services (CMS) has outlined documentation guidelines for behavioral health services.

Behavioral health services must meet specific requirements for reimbursement:

1. Psychotherapy services must be rendered by licensed practitioners.

  • “Psychotherapy services must be performed by a person licensed by the state where practicing, and whose training and scope of practice allow that person to perform such services,” states CMS (Coverage Indications, Limitations, and/or Medical Necessity).
  • Health Guide USA lists state-specific healthcare licensures at https://www.healthguideusa.org/medical_license_lookup.htm.
  • The rendering provider listed on the progress note must match the rendering provider listed on the claim. Each progress note must be authenticated by the rendering provider.

2. Services rendered must be medically necessary and contain documentation to justify services billed.

  • “For psychotherapy and psychoanalysis services, the medical record documentation maintained by the provider must indicate the medical necessity of each psychotherapy/psychoanalysis session,” states CMS (Coverage Indications, Limitations, and/or Medical Necessity).
  • Documentation must clearly reflect an intervention and the patient’s response to the therapeutic intervention delivered.

3. Time-based psychotherapy codes must reflect start/end times and/or duration of rendered services.

  • CPT® time rule:
Psychotherapy codesMinutes in code descriptorReporting time range
90832, 908333016-37

Coding and Billing Tips

Additionally, always verify with the payer which CPT® codes and diagnosis codes are reimbursable. This information should be outlined in your provider fee schedule. And when providing telehealth services, bill the appropriate modifier and place of service code per payer guidelines. CMS has identified in its telehealth list the psychotherapy codes you can bill as telehealth using an audio-only method of technology versus video conferencing.


American Psychiatric Association Practice Management Guides: www.psychiatry.org/psychiatrists/practice/practice-management/practice-management-guides

American Psychological Association Guidelines for Practitioners: www.apa.org/about/policy/psychological-practice-health-care.pdf

AAPC Behavioral Health Coding Training online course: www.aapc.com/training/behavioral-health-coding-training.aspx

CMS List of Telehealth Services

Letoria Leiba
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Letoria Leiba, LMHC, CPC, is a Florida licensed mental health counselor (#10499) with over 20 years of experience in behavioral health operations, working in various managed care organizations, employee assistance program organizations, mental health group private practices, and community mental health. She now works as a clinical claims integrity investigator, completing behavioral health audits. Leiba is considered a subject matter expert in investigations, working directly in the fraud, waste, and abuse arena, providing prepayment reviews, clinical analysis, and claims auditing.

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