CPT® 90837: Psychotherapy, 60 minutes with patient - JE Part B

In order to fulfill its contractual obligation with CMS, Noridian Healthcare Solutions (Noridian), your Medicare Contractor, performs pre-payment reviews in accordance with CMS direction. CMS is required by the Social Security Act to ensure that payment is made only for those medical services that are reasonable and necessary. Medical review assesses submitted documentation to validate provider compliance with Medicare payment rules and regulations, including coverage, coding and billing guidelines.

This is to update providers of the claim review findings for CPT® 90837: Psychotherapy, 60 minutes with patient. The results of this focused review are not a reflection on providers' competence as a health care professional, or the quality of care provided to patients. Specifically, the results are based on the documentation requested by Medicare and/or your facility's compliance with the required documentation.

The Jurisdiction E Part B Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of CPT® 90837: Psychotherapy, 60 minutes with patient The quarterly edit effectiveness results from April 1, 2025, through June 30, 2025, are as follows:

Top Denial Reasons

• Denial Reason 1 - Failure to return records
• Denial Reason 2 - Documentation does not support modifiers billed
• Denial Reason 3 - Documentation does not support the level of service billed

Educational Resources

• Failure to Return Records
• Psychotherapeutic Services and Documentation Requirements
• Noridian Modifiers

Education

Psychotherapy notes are defined in 45 CFR§164.501 as "notes recorded by a mental health professional which document or analyze the contents of a counseling session and that are separated from the rest of a medical record." The definition of psychotherapy notes excludes medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of administered treatment, results of clinical tests, and any summary of diagnosis, functional status, treatment plan, symptoms prognosis, ongoing progress and progress to date. This class of information does not qualify as psychotherapy note material. Physically integrating information excluded from the definition of psychotherapy notes and protected information into one document or record does not transform the non-protected information into protected psychotherapy notes.

If the medical documentation includes any of the information included in the definition of psychotherapy notes in §164.501, as stated above, the provider is responsible for extracting information required to support that the claim is for reasonable and necessary services.

If time spent is not documented, no payment will be made. Do not report psychotherapy of less than 16 minutes. Refer to Social Security Act 1862 (a)(1)(A), Medicare Claims Processing Manual, Medicare Program Integrity Manual Chapter 3, Section 3.3.2.6 and Medicare Benefit Policy Manual.