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 Brief Description
  Beneficiary identification, date of service, and provider of the service should be clearly identified on each page of the submitted documentation
  Initial psychiatric/psychological evaluation/mental status exam
  Mini mental status exam (MMSE) or similar test score
  Psychosocial Assessment
  Psychiatric evaluation and all behavioral/psychological/psychiatric tests that have been performed
  Individualized treatment plan for psychiatric services with updates
  Counseling Records
  Documentation to support time in/out or actual time spent
  Individual and group psychotherapy and beneficiary education and training
  Record of mental status
  Documented pharmacologic management to include prescription and dosage adjustment/changes
  Documentation to support virtual service(s) provided: Telehealth, E-Visit(s), Virtual Check-In
  Documentation supporting the diagnosis code(s) required for the item(s) billed
  Documentation to support the code(s) and modifier(s) billed
  List of all non-standard abbreviations or acronyms used, including definitions
  Any other supporting/pertinent documentation
  Documentation to support National Coverage Determination (NCD), Local Coverage Determination (LCD) and/or Policy Article
  Signature and credentials of all personnel providing services. Include a signature log or signature attestation for any missing or illegible signatures within the medical record
  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
  Advance Beneficiary Notice of Non-Coverage (ABN)/Notice of Medicare Non-Coverage (NOMNC)


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 Dec 09 , 2023

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.