Psychiatry Coding & Reimbursement Alert

Answer: When providing documentation for psychotherapy sessions, you will have to report the appropriate diagnosis code for which the patient is being provided these sessions by your psychiatrist. 

 

You will also have to make mention of the target symptoms, and the type of psychotherapeutic intervention that your clinician is using for the session. Some of the types of intervention that your clinician might be employing include cognitive behavioral therapy, interpersonal therapy, psychodynamic or psychoanalytical therapy, or cognitive analytical therapy. You will also need to document the progress towards achievement of the target goals.

 

Since psychotherapy codes are time based, you will need to accurately document the exact amount of time that your clinician spent in performing the psychotherapy session. You will also need to know that this time should not include the time your clinician spent in performing an evaluation and management of the patient or in pharmacological management.

So, when documenting time for a session that involved both an E/M service and a psychotherapy session, you will need to individually document the time spent for each service and not document time for the entire session. You will also need to report the appropriate psychotherapy code depending on the exact time spent in providing the psychotherapy part of the service and not on the time taken for the entire session.

 

Apart from these documentation details, you will need to include details such as date on which the session was conducted, the details of the clinician that provided the service, and a legible signature.