Psychotherapy billing gets harder when the documentation does not support the code on the claim. A note can seem fine at first but a review may show that some important details are missing.
With CPT 90838, this is worth paying attention to. The code is used for psychotherapy along with an evaluation and management service. It is an add-on code rather than a separate psychotherapy code. CMS lists it as a 60-minute psychotherapy service when it is reported with an E/M service.
That makes a quick review before billing a good idea. The review does not have to take much time. The main thing is to see if the note explains what happened during the session and supports the services listed on the claim.
What Is CPT 90838?
CPT 90838 applies when a provider performs psychotherapy with an evaluation and management service. It is different from CPT 90837 which describes 60-minute psychotherapy without an E/M service.
CMS lists 90833, 90836 and 90838 as psychotherapy add-on codes used with appropriate E/M services. The psychotherapy and E/M services must also represent significant and separately identifiable services. That distinction matters during an audit.
A note should not simply mention that an E/M service occurred and then add psychotherapy without showing what happened during the psychotherapy portion. The documentation should support both parts of the encounter.
Time also matters. CMS guidance treats psychotherapy codes as time-based services. For 90838 the psychotherapy portion must meet the applicable time threshold. CMS guidance identifies 53 minutes or more for the 60-minute psychotherapy code. The psychotherapy time should remain separate from the time used to determine the E/M service when applicable.
CPT 90838 Audit Checklist
Before billing CPT 90838, an organization can use a simple checklist to review the documentation. The exact requirements can vary by payer so the audit should also account for the applicable payer policy.
- Confirm the correct patient and date of service
Start with the basics. Check the patient information. Then confirm the date of service matches the encounter and the claim.
It sounds obvious but basic mismatches can create unnecessary billing problems. The medical record should clearly identify the patient and the date associated with the service.
CMS documentation guidance also expects medical records to contain appropriate patient identification information and the required provider signature or authentication.
- Confirm that psychotherapy actually occurred
The record should show that psychotherapy was part of the encounter. Look for documentation about the therapeutic work performed during the session. A general statement such as “patient doing well” does not explain enough about the psychotherapy service.
The note should show what the provider worked on with the patient during the session. This can include things like coping skills, behavior changes, emotional concerns, treatment goals or the interventions used during the visit.
CMS guidance also looks for documentation of the psychotherapy session and the techniques used to support therapeutic change.
- Check the psychotherapy time
Time is one of the most important items on the checklist. Review the note for the psychotherapy time. Depending on the payer and documentation policy this may appear as start and stop times or as a documented total time.
CMS guidance states that psychotherapy services are time-based. For psychotherapy performed with an E/M service, the record should distinguish psychotherapy time from the time used for the E/M service.
This is where a quick chart audit can help.
If the note does not clearly support the reported psychotherapy time, the billing team should stop and review the documentation before submitting the claim.
- Make sure the E/M service is documented separately
This is another major checkpoint. CPT 90838 does not replace the E/M code. It works alongside the appropriate E/M service.
The record should support the E/M service that the provider reports. It should also show that the psychotherapy portion represents a significant and separately identifiable service.
CMS specifically states that when providers report both E/M and psychotherapy on the same date, the two services must be significant and separately identifiable.
A billing reviewer should therefore look at both parts of the note rather than reviewing the psychotherapy section alone.
- Check that psychotherapy time does not get mixed with E/M time
This can be easy to overlook. A provider may spend time reviewing information, performing an examination or making medical decisions as part of the E/M service. That time should not automatically become psychotherapy time.
The documentation needs to make the distinction clear.
If a note lists one total visit time without explaining the psychotherapy portion then the reviewer may have difficulty determining whether the reported psychotherapy time meets the coding requirements.
CMS guidance explains that the total time used for psychotherapy does not include E/M time.
- Review the therapeutic interventions
A strong psychotherapy note should explain what the provider actually did during the session. This does not mean writing a long story about every conversation. It means giving enough information to show the clinical work that took place.
The documentation may include interventions such as supportive interaction, behavioral modification or interpretive approaches when those interventions apply to the encounter.
The provider should connect the intervention to the patient’s needs rather than simply listing techniques.
That small difference can make the note much easier to understand during an audit.
- Look for treatment goals and progress
The note should connect the session to the patient’s ongoing treatment. Review whether the documentation discusses progress toward treatment goals. If there was limited progress or a setback then the note can explain that too.
A treatment plan should not sit separately from every progress note with no connection between them. The session should make sense within the broader course of treatment.
CMS guidance includes periodic summaries of treatment goals and progress along with an updated treatment plan as part of psychotherapy documentation expectations.
- Check medical necessity
Medical necessity should always remain part of the review. Ask a basic question: Does the documentation explain why the patient needed the service?
The diagnosis, symptoms, treatment goals and interventions should make sense together. The note should support the need for ongoing treatment based on the patient’s situation.
CMS notes that medical necessity plays an important role in payment and that documentation should support the diagnosis and services reported.
A code alone does not establish medical necessity. The clinical record needs to support it.
- Verify the diagnosis and claim information
The diagnosis reported on the claim should match the documentation. This does not mean every note needs to repeat the same wording. The diagnosis should also match what the note says about the patient’s condition and treatment.
During the audit, compare the diagnosis in the note with the ICD-10-CM code used on the claim.
Also check the date, provider information, place of service and other claim details based on the payer’s requirements.
- Check provider eligibility
Not every provider can report every psychotherapy and E/M combination. The billing team should confirm that the provider meets the applicable payer and scope-of-practice requirements for the services billed.
CMS guidance states that psychotherapy codes involving E/M services have specific provider requirements.
This makes provider eligibility another useful checkpoint in a documentation audit.
Common Documentation Problems With CPT 90838
Some problems show up again and again during chart reviews. One common issue is vague psychotherapy documentation. The note says therapy occurred but does not explain the interventions or therapeutic work.
Another issue involves time. The record may mention a long visit but fail to separate psychotherapy time from E/M time.
Some notes also contain an E/M service and psychotherapy section that look almost identical. That can make it difficult to see whether the two services were actually separate.
Another problem is weak medical necessity documentation. The diagnosis may appear on the claim but the note does not clearly connect the patient’s condition with the treatment provided.
There can also be simple administrative errors. Incorrect dates, missing signatures or mismatched claim information may create problems even when the clinical service itself was appropriate.
These issues are exactly why a pre-billing audit can be useful.
A Simple Pre-Billing Review Process
A behavioral health organization does not necessarily need a complicated process to review every note. Start with a short checklist. A behavioral health chart audit tool can also help teams review records more consistently when they are handling a large number of charts.
First, confirm the patient and date. Then verify the psychotherapy time. Review the therapeutic interventions. Check the treatment goals and progress. Confirm the E/M service. Make sure the two services remain separately identifiable. Then review medical necessity and diagnosis information.
If something looks unclear, flag the record before submitting the claim.
The reviewer can then send the note back for clarification or correction when appropriate. This approach can help prevent avoidable claim issues instead of discovering them after a payer requests records.
Why Documentation Audits Matter
Documentation audits are not only about finding mistakes. They can also show where the documentation process needs improvement.
SAMHSA reported that 5.6% of U.S. adults, or about 14.6 million people, had serious mental illness in 2024. This gives some context to the amount of behavioral health care being provided and why keeping records clear and accurate matters.
If several providers consistently leave out psychotherapy time then the organization may need clearer documentation guidance. If reviewers repeatedly find weak treatment-goal documentation then supervisors may want to address that area during training.
Over time, the audit results can become useful feedback.
A good audit process should focus on patterns rather than only individual errors. One missing detail may be an isolated mistake. The same missing detail across many records points to a workflow problem.
Final Thoughts
CPT 90838 requires more than selecting the correct code on a claim. The medical record needs to support the psychotherapy service and the related E/M service. A pre-billing checklist can make that review easier.
Check the psychotherapy time. Review the interventions. Confirm treatment goals and progress. Make sure the E/M service stands on its own. Review medical necessity and diagnosis information. Finally, check the basic claim and provider details.
These steps do not guarantee payment because payer rules can differ. They do give billing and compliance teams a practical way to identify documentation gaps before a claim goes out.
When an organization handles a lot of behavioral health records, having a simple chart review process can keep things more consistent. It can also help spot the same documentation issues coming up across different records before they cause bigger billing or compliance problems.
