Q&A: Documentation and CPT coding for psychotherapy
Q: What elements must be included in a provider’s documentation of individual psychotherapy to ensure accurate CPT coding for these services?
A: Documentation for individual psychotherapy should include the following elements:
- Time the session began
- Individuals present
- Therapeutic modality
- Description of how the services benefit the patient
- Description of how the client reacted and behaviors exhibited
- A periodic summary of goals, progress toward goals, and an updated treatment plan
- Assessment of interactive complexity (if present)
- Time the session ended
Notably, the treatment modality does not refer to the type of psychotherapy provided (i.e., individual, group, or family therapy). Rather, this refers to the therapeutic techniques the clinician uses such as cognitive behavioral therapy, dialectical behavior therapy, and motivational interviewing.
The following time-based CPT codes are used to report individual psychotherapy:
- 90832, psychotherapy; 30 minutes with patient
- 90834, …; 45 minutes with patient
- 90837, …; 60 minutes with patient
The following CPT add-on codes (reported in conjunction with primary E/M codes 99202-99255, 99304-99337, 99341-99350) describe individual psychotherapy performed with an E/M service:
- 90833, …; 30 minutes with patient when performed with an E/M service
- 90836, …; 45 minutes with patient when performed with an E/M service
- 90838, …; 60 minutes with patient when performed with an E/M service
Per the CPT guidelines, coders should report the code closest to the actual time (i.e., 16-37 minutes for 90832 and 90833, 38-52 minutes for 90834 and 90836, and 53 or more minutes for 90837 and 90838). Coders should never report psychotherapy of less than 16 minutes duration.
Editor’s note: Stephanie Moore, CPC, CPMA, physician services educator at Wentworth-Douglass Hospital in Dover, New Hampshire, answered this question during the HCPro webinar, “Master Outpatient Behavioral Health Coding and Documentation.”
This answer was provided based on limited information. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.