Documentation for CPT code 90837 (Psychotherapy, 53+ minutes) must meet specific time and complexity requirements while capturing essential clinical information. Using the BIRP Notes format for 90837 billing requires understanding how this note structure aligns with CPT documentation requirements.
BIRP Notes Documentation for CPT 90837
Code Overview: CPT 90837
Service Description: Psychotherapy, 53+ minutes
Description: Individual psychotherapy for 53 or more minutes. Extended sessions allowing for in-depth work, complex cases, or intensive processing. Requires robust clinical documentation justifying extended time.
The CPT code 90837 carries specific documentation requirements that differ from other mental health service codes. Your clinical notes must clearly demonstrate that the service provided meets the definition of this code and justifies the complexity and time involved. The BIRP Notes format provides an excellent structure for capturing this required information.
Documentation Requirements for CPT 90837
Essential Documentation Elements
- Chief Complaint or Reason for Visit: Clear statement of why the client is seeking services and what brought them to this session
- History of Present Illness: Detailed exploration of current symptoms, their onset, duration, and progression since last visit
- Relevant Medical/Psychiatric History: Background information affecting current treatment and functioning
- Current Symptoms and Status: Specific documentation of symptoms present and their severity or intensity
- Assessment/Diagnosis: Clear diagnostic formulation with DSM-5 codes and justification for diagnosis
- Functional Assessment: How symptoms affect occupational, social, and personal functioning
- Risk Assessment: If applicable, documentation of suicide risk, homicide risk, substance use, or other safety factors
- Treatment Interventions: Specific therapeutic interventions provided during this encounter
- Response to Interventions: How the client responded to treatment and progress toward goals
- Treatment Plan/Next Steps: Continuation of current approach or modifications based on client response
How to Document with BIRP Notes for CPT 90837
The BIRP Notes format maps well to CPT documentation requirements when each section contains the required elements:
Behavior
Document relevant information for this code's requirements.
Intervention
Document relevant information for this code's requirements.
Response
Document relevant information for this code's requirements.
Plan
Detail the treatment plan, specific interventions being provided, goals for ongoing treatment, and any modifications to the existing plan.
Common Documentation Mistakes for CPT 90837
- Vague Symptom Documentation: Avoid generic statements like "client reports doing okay." Be specific about which symptoms are present, which have improved, and which persist.
- Missing Time/Complexity Justification: Don't simply bill the code; document why this encounter required the time and complexity represented by the code you're billing.
- Insufficient Medical Necessity: Always connect symptoms to diagnosis and show how treatment addresses the documented symptoms and functional impairment.
- Incomplete Risk Assessment: If mental health treatment is involved, address safety. Document suicide risk assessment, substance use status, or other safety factors as appropriate.
- Generic Treatment Plans: "Continue current therapy" is insufficient. Specify what you're doing and why, with reference to the client's goals and presenting problems.
- Inconsistent Diagnoses: Ensure your billing diagnoses match your documentation. If you bill for depression, document depressive symptoms. If you bill for anxiety, document anxiety symptoms.
- Missing Progress Indicators: Show how the client is progressing. Compare to previous session, note improvements, identify barriers, adjust interventions based on response.
Audit Red Flags for CPT 90837
Insurance auditors and peer reviewers look for these red flags when reviewing claims for CPT 90837:
- Documentation that doesn't support the complexity or time of the code billed
- Inconsistency between diagnosis billed and symptoms documented
- Lack of progress notes over time (shows ongoing medical necessity)
- Missing risk assessment when treating mental health conditions
- Generic, template-like notes that could apply to any client
- No clear treatment plan or goals documented
- Inadequate functional assessment (documentation of how condition affects daily life)
- Notes that don't reflect the time reported (very brief notes for longer billing times)
Sample Note Example for BIRP Notes for CPT 90837
Intervention: Therapist provided 60 minutes of individual psychotherapy using CBT and supportive therapy. Interventions included identifying automatic thoughts related to perceived criticism, cognitive restructuring, grounding skills for physiological arousal, and problem-solving around a staged return to communication. Therapist also explored triggers, assessed safety, and reinforced use of a coping plan between sessions.
Response: Client was engaged throughout the session, able to identify multiple distortions, and practiced reframing statements in session with prompting. Client reported decreased distress from 8/10 to 5/10 by end of visit and stated the grounding exercise was helpful. Client verbalized understanding of the coping plan and agreed to limit avoidance behaviors.
Plan: Continue weekly individual psychotherapy for ongoing symptoms causing functional impairment at work. Client will practice daily grounding, complete a thought record before next session, and initiate one brief work-related email using coping strategies. Next session will reassess anxiety severity, work functioning, and need for escalation if symptoms worsen.
Example only. Replace with session-specific details.
Documentation Considerations for BIRP Notes for CPT 90837
Document Why 90837 Was Medically Necessary
CPT 90837 requires more than simply stating the session lasted 60 minutes. The note should show why an extended psychotherapy session was clinically indicated, such as severe symptom burden, crisis-level distress, complex trauma processing, safety assessment, or significant functional impairment. Include the mental health diagnosis, symptom severity, and the treatment need for additional time to address therapeutic goals that could not reasonably be completed in a shorter visit.
Be Precise About Time and Session Scope
For 90837, the record should clearly support a psychotherapy session of 60 minutes, not a different timed code. Document the actual face-to-face or telehealth psychotherapy time in a way that aligns with the payer’s rules, and avoid rounding ambiguously. The content should also reflect a full psychotherapy encounter, not a medication check, case management visit, or brief supportive contact that would fit a lower-level code.
Expect Payer Scrutiny on Frequency and Pattern
Many payers review repeated use of 90837 because it is a higher-reimbursing code. Be cautious if sessions are consistently billed at 60 minutes without corresponding clinical complexity, progress, or rationale. If the patient is seen weekly or more often, document why longer psychotherapy is necessary and how the intervention differs from a shorter visit. Payer policies may also require specific telehealth modifiers, place-of-service codes, or diagnoses.
Avoid Common Audit Triggers in the Note
Audit risks include vague language like 'provided therapy,' copied-forward notes, lack of individualized interventions, and outcomes that do not match the stated treatment plan. The note should show the patient’s presenting problem, specific psychotherapy techniques used, the patient’s response, and a clear next step. Also ensure the note supports that the billed service was psychotherapy by a qualified professional and that any co-occurring services are not double-counted.
FAQ — BIRP Notes for CPT 90837
What must a BIRP note include to support billing CPT 90837?
A BIRP note for CPT 90837 should show a 60-minute individual psychotherapy session with enough clinical detail to justify the code. At minimum, it should document the patient’s current behavior or symptoms, the psychotherapy interventions used, the patient’s response to those interventions, and the plan for ongoing treatment. It should also clearly connect the session to a diagnosis, functional impairment, and a medically necessary need for extended treatment time.
Do I need to write the exact start and stop time for 90837?
Many payers expect time support for 90837, and documenting start and stop times is often the safest approach. Even when exact times are not required by every payer, the note should clearly support a full 60-minute psychotherapy session. Avoid vague statements such as 'extended session' without time detail. If you use telehealth or if your payer has special timing rules, follow that policy closely and make sure the duration is consistent with the code.
Can I use 90837 if the session included case management or safety planning?
Yes, but only if psychotherapy remained the primary service and the note supports that the session was a 60-minute psychotherapy encounter. Brief coordination, safety planning, or discharge arrangements can be part of the visit, but they should not replace the psychotherapy content. Be careful not to bill other services separately unless payer rules allow it and the documentation clearly distinguishes the work performed. The chart should show that the psychotherapy was clinically central to the visit.
What documentation issues most often lead to denial or recoupment for 90837?
Common problems include insufficient time documentation, notes that are too generic, lack of evidence that 60 minutes was medically necessary, and repeated use of 90837 without clinical justification. Payers also flag cloned notes, mismatched diagnosis and treatment content, and records that do not show individualized psychotherapy. Another issue is billing 90837 for sessions that appear to be supportive counseling, check-ins, or administrative calls rather than true psychotherapy.
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Further Reading
- CMS Documentation Requirements — Provides official guidelines on documentation standards required for Medicare billing and CPT code compliance.
- APA Documentation Guidelines — Offers detailed best practices for clinical note-taking, including structured formats like BIRP relevant to psychotherapy.
- HHS HIPAA — Covers privacy and security regulations essential for maintaining confidentiality in psychotherapy documentation.