Documenting Add On Psychotherapy Time

Does Add on Therapy Need Start and Stop Times?

Proper documentation of time for psychotherapy services is not only a coding requirement but also a fundamental aspect of transparent and accountable healthcare delivery.

So....Do the minutes of psychotherapy need to be provided consistently and documented as such -- meaning documented as a start and stop time? NO. According to CMS, "in cases where psychotherapy is combined with an E/M service (CPT codes 90833, 90836, and 90838), it is recognized that the psychotherapy time may not always be continuous. When the documentation of time is relevant for coding and payment purposes, time may be documented with start and stop times or with total time."

Recognizing the diversity of clinical practices, the documentation of time can take different forms. If you tend to differentiate the E/M section of your visit from the add on psychotherapy time, then you may document the add on psychotherapy as start and stop times or as total minutes. If your sessions tend to integrate the two, lumping a few minutes of therapeutic intervention at different times throughout the session, you can document total minutes and not worry that your documentation is lacking. This flexibility acknowledges the varied nature of mental health treatment scenarios and ensures that accurate information is conveyed for coding and payment purposes.

Source: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=57520&ver=29#:~:text=This%20service%20is%20used%20in,psychotherapy%20(CPT%20code%2090853).