Documentation for CPT code 90837 (Psychotherapy, 53+ minutes) must meet specific time and complexity requirements while capturing essential clinical information. Using the GIRP Notes format for 90837 billing requires understanding how this note structure aligns with CPT documentation requirements.
GIRP 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 GIRP 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 GIRP Notes for CPT 90837
The GIRP Notes format maps well to CPT documentation requirements when each section contains the required elements:
Goals
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 GIRP Notes for CPT 90837
Intervention: 60-minute psychotherapy session conducted individually using a GIRP structure. Therapist used CBT-based cognitive restructuring, grounding practice, and guided problem-solving to address catastrophic thinking about an upcoming performance review. Reviewed recent sleep hygiene behaviors and reinforced use of paced breathing during early panic cues.
Response: Client was engaged, tearful at times, and able to identify automatic thoughts contributing to anxiety. Reported two panic episodes this week, both after workplace conflict. Client practiced grounding in session and stated distress decreased from 8/10 to 4/10. Demonstrated improved insight into triggers and was receptive to homework.
Plan: Continue weekly 60-minute psychotherapy to address anxiety symptoms, functional impairment at work, and sleep disruption. Client will practice paced breathing twice daily, complete a thought log before next session, and track panic triggers and duration. Monitor symptom severity, coping skill use, and impact on occupational functioning next visit.
Example only. Replace with session-specific details.
Documentation Considerations for GIRP Notes for CPT 90837
Document Medical Necessity, Not Just Supportive Counseling
For CPT 90837, your GIRP note should clearly show why a 60-minute psychotherapy session was medically necessary. Link the presenting symptoms to functional impairment, symptom severity, or risk factors, and describe active treatment interventions. Payers generally want to see more than rapport-building or check-ins; the note should reflect a clinically significant mental health condition requiring extended individual psychotherapy.
Time Must Support the 90837 Level of Service
CPT 90837 is for psychotherapy lasting 60 minutes, typically reported when the time spent is 53 minutes or more. Your documentation should support the full duration with a psychotherapy focus, not just add-up time spent on administrative tasks. If the session included interruptions, crisis calls, or collateral contact, document only the time that qualifies for psychotherapy and make sure the total still supports 90837.
Payer Scrutiny Is Higher for Extended Sessions
Many insurers audit 90837 more closely than 90834 because it is higher cost and easier to overuse. They may look for diagnosis consistency, symptom acuity, and reasons a shorter session would not have been sufficient. GIRP notes should show individualized treatment, active intervention, and progress or ongoing barriers. Repetitive wording across sessions can raise questions about medical necessity.
Common Audit Triggers Include Vague Goals and Weak Progress Detail
Audit problems often arise when the note does not connect the intervention to the goal or when the response is vague, such as “client discussed week” or “stable.” For 90837, the note should show specific symptoms, observable response, and next-step treatment planning. Lack of measurable goals, missing duration, or inconsistent diagnosis documentation can make an otherwise legitimate session difficult to defend.
FAQ — GIRP Notes for CPT 90837
What should a GIRP note include to support CPT 90837?
A strong GIRP note for CPT 90837 should show a clear goal tied to a mental health diagnosis, an individualized psychotherapy intervention, the client’s response to treatment, and a plan for continued care. Because 90837 is an extended individual psychotherapy code, the documentation should also support the need for a 60-minute session by showing symptom complexity, functional impairment, or risk that required more than a shorter visit.
How do I document time for CPT 90837 in a GIRP note?
Document the psychotherapy time clearly in the note or in your template so the record supports the 90837 service level. In most payer policies, 90837 is appropriate when the psychotherapy portion is 53 minutes or more. Avoid counting non-billable activities such as scheduling, general administrative work, or unrelated collateral tasks. If you use a GIRP template, include wording that the session was conducted for 60 minutes and was psychotherapy in nature.
Can I bill 90837 if the session was primarily supportive and not highly structured?
Possibly, but the note still needs to show medical necessity and active psychotherapy. Supportive therapy can qualify if it is treating a diagnosable mental disorder and the session addresses symptoms, coping, or functioning in a clinically meaningful way. The documentation should not read like a social support conversation. Show what intervention was used, why it was needed, and how it relates to the client’s treatment goals.
What are the biggest reasons insurers deny 90837 claims?
Common denial reasons include insufficient time documentation, notes that do not show why a 60-minute session was needed, weak linkage between diagnosis and treatment goals, and progress notes that are too generic. Some payers also flag repeated 90837 billing without evidence of higher complexity. To reduce denials, make sure the GIRP note reflects the specific symptoms treated, the psychotherapy interventions used, and the client’s response and ongoing need for treatment.
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Further Reading
- CMS Documentation Requirements — Provides official guidelines on documentation standards required for billing CPT codes including psychotherapy services.
- APA Documentation Guidelines — Offers detailed recommendations on clinical documentation practices relevant to psychotherapy notes.
- HHS HIPAA — Covers privacy and security rules essential for maintaining confidentiality in psychotherapy documentation.