A message from Dr. William Beecroft, medical director of behavioral health
Importance of correct behavioral health documentation

Medical record documentation has undergone many upgrades over the past 30 years, but some things remain the same.

There’s a need for the presenting circumstances (chief complaint — the focus of treatment that day), history of present illness (interval history if not the initial visit), review of systems, past history, family history (in this case psychiatric and medical history), mental status exam — any physical exam component as well if it’s completed, assessment and plan.

The following table from the American Psychological Association identifies these components and the ones necessary for billing consideration.

Billing rules, which are separate from clinical documentation, also have gotten more detailed with the first major revision in 1995, a second one in 2003 and then the most current edition of evaluation and management, or E/M, documentation requirements in 2021-2025 for telemedicine E/M notes. The advent of electronic medical records has produced many more routine operations to make sure all the boxes have been checked in the evaluation and management of the member’s care. 

Many times, we forget that the medical record is not only a clinical document outlining care provided that day, but your considerations with resulting plan of care. The general rule of thumb is, if an issue isn’t documented, you did not address it or consider it. The following would be important to include:

• A suicide risk assessment
• A metabolic analysis of a person on a medication with metabolic syndrome as a consequence
• An Abnormal Involuntary Movement Scale, or AIMS

Blue Cross Blue Shield of Michigan has outlined in the Blue Cross Commercial Provider Manual the required information to be included in E/M and psychotherapy notes.

To access our provider manuals:

1. Log in to the provider portal at availity.com.**
2. Click on Payer Spaces on the menu bar, and then click on the BCBSM and BCN logo.
3. Under the Resources tab, click on Provider manuals.
4. In the Blue Cross Commercial Provider Manual, open the “Documentation Guidelines for Physicians and Other Professional Providers” chapter and review the section titled “Mental health and substance use disorder services.”

Treating toward a target is important in all our work, so the results of a screening tool that you have used would be documentation of the effect of the therapeutic intervention and could be added to an update of your plan of care progress reporting. Risk assessment is important for all of us, so these components will fit within the key components of the progress note documentation. All these parts of the record should justify the medical necessity of the visit, setting the member up for a positive outcome on his or her journey toward wellness.   

Billing of a progress note (consultation, assessment or routine follow-up of established patient)

Documentation supports medical necessity as well as justification of billed claims. The following sections go into detail with some examples of the key elements that will be monitored to justify the level of care billed. These are clearly outlined in American Medical Association and Centers for Medicare & Medicaid Services documents. E/M visits are covered below, but in general can be billed based on time or the medical decision-making criteria. These codes have been assigned a time to accomplish these services based on the amount of work necessary to complete them. 

E/M code selection can be done based on medical decision making, known as MDM, or time, never both. The level of MDM selected is driven by the nature of the presenting problem on the date of the encounter. Problems you’re not managing or not addressing at that encounter can’t be counted toward the number of problems.    

To qualify for a particular level of MDM, two of the following three elements for that level of MDM must be met or exceeded:

• Number and complexity of problems addressed and treated during the session
• Problem: A problem is a disease, condition, illness, injury, symptom, sign, finding or complaint addressed at the encounter, with or without a diagnosis being established at the time of the encounter.
• Problem addressed: A problem is addressed or managed when it’s evaluated or treated at the encounter by the physician or other qualified health care professional reporting the service.
• Amount or complexity of data reviewed and analyzed
• Risk of complications or morbidity or mortality included in patient management

See Table 2 – CPT E/M Office Revisions Level of Medical Decision Making (MDM)** by the AMA for more information.

Selecting level of service based on time

The alternative to using MDM, which can be used only when no psychotherapy add-on codes are involved, is to base the level of the visit on total time. Medical necessity and description of medical decision-making, assessment, plan, and so on, must still be documented; however, time is the criteria that must be met and documented in this case.

When time is used for reporting E/M services codes, the time defined in the service descriptors for the E/M code is used for selecting the appropriate level of services. Time is defined as the total time spent by the health care professional on the date of the encounter, both the face-to-face time with the patient or family or caregiver and non-face-to-face time personally spent by the physician or qualified health professional on the day of the encounter. Time includes tasks such as:

• Reviewing tests
• Obtaining or reviewing a separately obtained history
• Performing a medically appropriate evaluation or exam
• Counseling and educating a patient, family or caregiver
• Ordering medications tests or procedures
• Referring and communicating with other health care providers (not separately reported)
• Interpreting, independently, test results and communicating results to a patient, family or caregiver (not separately reported)

Counselling in the above context, when using time, can refer to talk therapy, motivational interviewing, behavioral activation or psychoeducation regarding diagnosis, treatment options, side effects or risk benefit of treatment. The Centers for Medicare & Medicaid Services has described average time frames for these activities to be completed within and should advise your code selection.

Correctly using the psychotherapy add-on code

When using a psychotherapy add-on code, MDM for the E/M code must be used, not time. The documentation needs to support two of the three elements of MDM for the E/M code used. For example, if using *99213 and *90833, the visit must support two of the three elements of MDM required for *99213. To report both E/M and psychotherapy, the two services must be significant and separately identifiable. An E/M service is significant and separately identifiable from a psychotherapy service performed at the same encounter, if there is no overlap in the work associated with the E/M and the work associated with the psychotherapy service. Documentation of the psychotherapy session must follow the criteria and elements outlined in the provider manual, found on our provider portal, for psychotherapy.

Add-on psychotherapy can’t be addressing issues raised in the E/M section of the visit (in other words, the time spent by the psychotherapist on the patient’s medical history, examination and medical decision-making when used for the E/M service isn’t part of the time spent on psychotherapy). The documentation for such a visit must not only include support of the rationale for the E/M code used for that visit, it also needs to have the documentation to support the psychotherapy services.

When considering time, keep in mind that the E/M work requires time, which should be accounted for within the total time of the visit. Higher complexity E/M work requires more time. When added to the time attributed to psychotherapy, the total time of the visit should make sense. For example, say you met with a patient for a total time of 20 minutes and billed a *99214 and *90833. Because *90833 must account for at least 16 minutes of the total time of the visit, it doesn’t make sense that the complex work of a *99214 was completed in four minutes.

The total time of the visit must be considered, subtracting the time of the E/M portion, and the remaining time spent in psychotherapy. The psychotherapy portion of the visit can follow the CMS 50% rule, which for shorter timed codes may not allow for adequate time to complete all the tasks and provide meaningful psychotherapy input to justify the service based on medical necessity. For instance, a patient has a therapist he or she sees weekly to treat anxiety using cognitive behavioral therapy, or CBT, the rational and medical necessity for psychotherapy add-on with scheduled medication reviews should be considered. Ask yourself, does the member really need two therapists, who may or may not be collaborating on the therapeutic process, to have optimal outcome or will it create chaos and confusion for the member? 

Treatment must be individualized to the patient, and not every patient may require psychotherapy with E/M services. Psychotherapy, in addition to E/M services, shouldn’t be justified by the minutes allotted by the practice for an appointment. Psychotherapy is an identifiable service that needs to be justified in the plan of care assessing the entirety of treatment for that individual’s best interest.

Psychotherapy services 

Psychotherapy evaluation and the continuing progress notes have required elements as outlined by the AMA and CMS:

• The medical record should document the target symptoms; goals of therapy and methods of monitoring outcomes; and why the chosen therapy is the appropriate treatment modality (either in lieu of, or in addition to, another form of behavioral health treatment).
• The patient’s medical record should contain documentation that fully supports the medical necessity for psychiatry and psychological services as Medicare covers it. This documentation includes, but is not limited to, relevant medical history, physical examination (mental status examination), results of pertinent diagnostic tests or procedures.
• Individual psychotherapy CPT codes should be used only when the focus of treatment involves individual psychotherapy.
• Medical records must document the patient’s capacity to participate in, and benefit from, psychotherapy, if psychotherapy is the chosen treatment. The estimated duration of treatment (number of sessions) should be specified. There should be documentation in the medical record that the treatment is expected to improve the health status or function of the patient. These CPT codes wouldn’t be used as generic psychiatric service CPT codes when other CPT codes such as an E/M service or pharmacological CPT codes would be more appropriate.
• Documentation must be available and may be requested before payment. If the claim doesn’t indicate that documentation is available, it will be denied.

Blue Cross requires the following components of a psychotherapy progress note: 

• Patient identification. Time to start and time to stop. Psychotherapy is based solely on time, hence the need for start and stop times.
• Location of service and if telemedicine technology is used
• Presenting problem
• Detailed diagnosis
• Any change in diagnosis and supporting details
• Progress toward treatment goals
• Results of interval homework or practice of prior intervention
• Assessment of current and long-term risk
• Interventions to minimize risk and contingency management (advanced directive or crisis plan) of interval worsening
• Interventions used
• Therapeutic interventions
• Session details
• Individual’s response to those interventions
• What worked
• What didn’t
• Any changes to interventions going forward.
• Diagnosis
• Follow-up visit schedule and objectives, homework or practice
• Signature, date, credentials

Blue Cross and Blue Care Network have outlined additional components of the medical record in the behavioral health sections of the provider manuals. View these documents for more information:

• Behavioral health medical record documentation requirements and privacy regulations – for services other than ABA
• Behavioral health medical record documentation requirements for autism services
• “Behavioral Health” chapter of the BCN Provider Manual
• For the Blue Cross Commercial Provider Manual, see “To access our manuals” earlier in this article.

CMS has outlined expected time frames to bill for psychotherapy levels of care.
Psychotherapy notes are discoverable so you need to document all the activity including screening and risk, boundary issues, and interventions that might pertain to standard of care for psychotherapy in every note.

Providing specialty types of psychotherapy, the documentation might look slightly different in detail, but the key components remain the same. Cognitive behavioral therapy, or CBT, and dialectical behavior therapy, or DBT, for instance, will have some updates on the interim work that was done by the member between sessions, possibly reviewing journals or if electronic data is used for collection, review of a report generated by the program would be discussed and processed in the session. Acceptance and commitment therapy or social rhythm therapy would likely have similar but different concepts covered in that section of the document. Exposure and response prevention, or ERP, and eye movement desensitization and reprocessing, or EMDR, would also look different in the reporting of progress and the work done in the session.  

Autism specific psychotherapy services, or ABA

For autism services, a version of psychotherapy, we have outlined expectations for documentation that are a combination of the CMS requirements for psychotherapy notes.
Blue Cross’ specifications, which were developed during a two-year process more than six years ago, are a combination of CMS rules, the output of an independent workgroup comprised of an autism community organization and several health care providers. This was to outline what is felt by professionals and community stakeholders, experts in the field, to be the standard of care. This combination of key items is outlined in detail in our provider manuals. These are similar to the expectations of other psychotherapists or medical providers and should be considered a baseline for measurement of the service given along with quality of care for our members.   

Summary

Documenting is an important aspect of our professional lives. It gives a developing clinical record of the services provided, the assessments and evaluations, risk assessments, what has worked and what did not work, and successes that the individual has had over time in such a way that another provider later might be able to pick up that care later and capitalize on the work you have accomplished. It also functions as a legal document outlining your care, professional intervention, thought processes in your treatment, coordination of care with others and the level of care you have provided that individual.

Thank you for all the care you provide our members.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2024 American Medical Association. All rights reserved.

**Blue Cross Blue Shield of Michigan doesn’t own or control this website.

References:

1. 2023 CPT E/M descriptors and guidelines**
2. Psychiatry.org - 2025 Billing and Documentation Update for Psychiatrists**
3. LCD - Psychiatric Diagnostic Evaluation and Psychotherapy Services (L33252)**

Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association.