How to Document Psychotherapy Sessions

Although there are no official guidelines for documenting psychotherapy in patients’ medical records, providing such documentation is as important as providing it for evaluation and management (E/M) services.

In May, a contractor for the Centers for Medicare and Medicaid Services (CMS) sent a document called a Comparative Billing Report (CBR) to more than 4,000 psychiatrists, comparing their billing practices for psychotherapy services with those of other psychiatrists in their state and across the United States. The CBRs cited previous reports on improper Medicare payments for psychiatry services and indicated that the reason the services were found improper was primarily due to insufficient documentation.

Although many of the errors found in earlier assessments were made by nonphysician psychotherapists, the CBRs defined what constitutes appropriate documentation that all psychiatrists who treat Medicare patients will find useful. It is similar to guidance that APA has long given its members.

• Date of service

• Diagnoses

• The time spent providing face-to-face psychotherapy with the patient and/or family members (For an encounter that also includes medical E/M services, the psychotherapy time should be differentiated from the E/M time.)

• The type of therapeutic intervention (for example, insight oriented, supportive, behavior modification)

• Target symptoms

• Progress toward achievement of treatment goals (This means, of course, that the patient record must include a treatment plan, although you do not need to refer to it in the documentation for each session.)

• For psychotherapy lasting more than 52 minutes (90837, 90838), the reason the session required this length of time

Previously, these seven items fulfilled the requirements for psychotherapy documentation, and when all were present, psychiatrists have not had problems when audited.

The CBRs refer to documentation requirements that are consistent with those of two Medicare administrative contractors (MACs). One of them—Cahaba Government Benefit Administrators, which is the MAC for Alabama, Georgia, and Tennessee—requires three extra pieces of information:

• The degree of patient interaction with the therapist

• The reaction of the patient to the therapy session

• Any changes in the patient’s symptoms or behavior as a result of the therapy session (This item is questionable since it is unlikely that such changes can be determined at the time the session is documented. Perhaps the MAC meant to refer to the previous session.)

Keep in mind that notes about personal information that emerges during the psychotherapy session beyond the seven points listed above should not be included in a patient’s medical record. Personal notes taken during the session to guide future treatment should also be kept separate from the medical record. Under HIPAA, the patient’s insurer and the patient can legally access the medical record, but they cannot access your record. ■