Wiki Outpatient psychotherapy documentation - start/stop times?


Pitsburgh, PA
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Hello. When billing with E&M, do our psychtherapy notes need to contain specific start and stop times for the psychotherapy portion of the visit, or is an overall time statement permitted, example "18 minutes was spent". Any insight is greatly appreciated. Thank you so much!
According to the guidelines for the CPT add-on codes for psychotherapy performed during the same visit as an E&M don't specifically state which way the time should be documented for the psychotherapy code, so either using start & stop times or total time spent on the psychotherapy service is allowed.

From an commercial insurance perspective the ideal way to document the psychotherapy service is by listing start & stop times when an E&M is also being provided on the same DOS. Then it is very clear as to how much time was spent on the psychotherapy service which is a time-based code and if the claim was to be audited with the medical records for the visit there won't be any question on how many minutes were spent on the psychotherapy portion of the visit. I know that documenting start and stop times are a hassle for any provider who performs time-based services compared to the provider listing the total time spent on a service. However, it is much easier to defend any question of whether the documentation supports the services billed based on total time when the start and stop times are listed.

I understand that this is not practical in all clinical scenarios but when I audited claims which were coded based on time, the medical records that had specific start and stop times were very easy to audit as the information was clear cut on how much time was spent on a service. When providers simply document total time spent and the patient has a more clinically complex or involved condition it is much easier for an auditor to start to question if the statement on total time spent and possibly down-code or deny a service as not supported. Especially, if an insurance company is looking at "impossible days" as an audit concept due to the high volume of E&Ms or other time-based service being billed by a given provider who appears to be an outlier in their region for their specialty.

Also, per the CPT guidelines time cannot be used for leveling the E&M when billing it with psychotherapy services, the leveling is to be based on the MDM.
Here are the guidelines:

However, it is ultimately up to your provider(s) or practice to decide on which is the best way to document the time in a manner that is not overly burdensome for them and at the same time supports the time billed for a time-based procedure.