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Psychotherapeutic Services and Documentation Requirements

Certain Psychiatric/Psychotherapy CPT codes are used in conjunction with an Evaluation and Management Service (E&M) code and are payable if documentation requirements are present. Each distinct service must be separately identifiable.

Medical Documentation Requirements

  • The E&M code selection must be based on the elements of the history and exam and medical decision making requirements. This must be identifiably separate from the psychotherapeutic service.
  • The psychotherapy code is chosen based on the amount of time spent exclusively on the psychotherapeutic service provided. This must be identifiably separate from the E&M service. This is designated by the use of an add-on code.
  • Time spent for the E&M service is separate and cannot be used as criteria for the psychotherapeutic service.
  • Time spent for the therapeutic service is separate and cannot be used to meet criteria for the E&M service.
  • Time is indicated in the psychotherapy CPT code and therefore must be clear in the documentation that this time was spent exclusively on the psychotherapy service, not the total time for both the E&M service and the psychotherapy service.


Last Updated Jul 16, 2018