# Psychotherapy documentation requirements



## dtweedy (Sep 29, 2014)

I am new to coding Psychotherapy, I am on the reimbursement side.  Can payers request the psychotherapy documentation for reimbursement?  It is difficult to reimburse for documentation submit that looks like this for 90837." Patient  had 60 minutes of individual psychotherapy"???

Any help would be greatly appreciated.

Deborah., CPC


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## mitchellde (Sep 29, 2014)

Of course the payer can request the complete chart note.  If what you stated above is all you have for a chart note then as the payer you may deny the claim. Chart notes may not be created after the claim is submitted.  If you request the chart note and that is what was received and then on denial you receive a different chart note, I would request the electronic time stamp of when the latest note was created.


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## dtweedy (Oct 2, 2014)

Thanks


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## MJ4ever (May 9, 2015)

Documentation requirements:

Type of therapy provided (individual/family w/ or without patient present/group/crisis)

Therapeutic technique used, i.e., CBT, EMDR

Content of the session; synopsis of showing that the patient's signs and symptoms, dx, was alleviated.

Total time in session.

90832 = 16-37 minutes
90834 = 38-52 minutes
90837 = 53 minutes or more

a minimum of 16 minutes has to be provided to be able to code for 90832


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## amys2361 (Nov 2, 2015)

MJ4ever said:


> Documentation requirements:
> 
> Type of therapy provided (individual/family w/ or without patient present/group/crisis)
> 
> ...



Should the note document the start and stop times? Or can it just state total time in session?
Also,if PMHDNP sees patient for med mgmt and then a couple hours later, our LMSWR sees the patient for psychotherapy, do we bill the office visit with modifier 25  and then the example 90834 or use the add on code without the mod 25?

Much help would be appreciated. New to bh coding!!
Amy StGeorge, CPC


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## Kristen Bensel (Feb 3, 2016)

amys2361 said:


> Should the note document the start and stop times? Or can it just state total time in session?
> Also,if PMHDNP sees patient for med mgmt and then a couple hours later, our LMSWR sees the patient for psychotherapy, do we bill the office visit with modifier 25  and then the example 90834 or use the add on code without the mod 25?
> 
> Much help would be appreciated. New to bh coding!!
> Amy StGeorge, CPC




There needs to be a statement indicating time spent with the patient. It can be as simple as a  "Total Time spent with Client: 45 minutes. start and stop times are not necessary unless you are doing E&M with Psychotherapy. At that point, there needs to be a statement about how much time was spent for the therapy portion separate from the E&M.

If they are two separate providers that can bill for services, then they would be two separate encounters. you wouldn't need to append a modifier to their services. 

Hope that helps!


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