Mental Health Documentation Requirements

It is expected that patient's medical records reflect the need for care/services provided. The listing of records is not all inclusive. Providers must ensure all necessary records are submitted to support services rendered. They may include:

Check box if submitted Brief Description
  Individual and group psychotherapy and beneficiary education and training
  Individualized Treatment Plan for Psychiatric Services with Updates
  Documented pharmacologic management to include prescription and dosage adjustment/changes
  Counseling Records
  Psychiatric diagnostic evaluation or psychotherapy face-to-face encounter, including the time spent in the psychotherapy encounter
  Admitting diagnosis along with any diagnosis of comorbid disease and the psychiatric diagnosis
  Psychiatric evaluation All behavioral/psychological/psychiatric tests that have been performed
  Initial psychiatric/psychological evaluation/mental status exam
  All behavioral/psychological/psychiatric tests that have been performed.
  Documentation of a second opinion of a psychiatrist who is not involved in the care of the beneficiary
  All group psychotherapy notes including number of participants
  Beneficiary name and date of service on all documentation
  Documentation as required in LCD or NCD
  Any additional documentation to support the reasonable necessity of the service(s) performed
  Advance Beneficiary Notice
  Signature log or signature attestation for any missing or illegible signatures within the medical record (all personnel providing services)
  Signature attestation and credentials of all personnel providing services
  If an electronic health record is utilized, include your facility’s process of how the electronic signature is created. Include an example of how the electronic signature displays once signed by the physician


Multiple CMS contractors are charged with completing reviews of medical records. See Identifying Which Entity Completed a Part B Claim Review for detailed information about each of these contractors.

Documentation Submission

Once a provider/supplier compiles all the necessary documentation, it is important to submit them to the appropriate contractor according to the request received. Select the request below to view the appropriate submission instructions.

View the Mental Health webpage for additional information and resources.

See also the Psychotherapeutic Services and Documentation Requirements webpage.


Last Updated Tue, 26 Oct 2021 15:33:02 +0000

Documentation Requirements Disclaimer

The documentation requirements contents/references provided within this section were prepared as educational tools and are not intended to grant rights or impose obligations. Use of these documents are not intended to take the place of either written law or regulations.

The listing of records is not all inclusive. Providers must ensure all necessary records are submitted to support services rendered.

Important that physician intent, physician decision and physician recommendation to provide services derived clearly from the medical record and properly authenticated.

The submission of these records shall not guarantee payment as all applicable coverage requirements must be met.