Documentation for CPT code 90837 (Psychotherapy, 53+ minutes) must meet specific time and complexity requirements while capturing essential clinical information. Using the Progress Notes format for 90837 billing requires understanding how this note structure aligns with CPT documentation requirements.
Progress 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 Progress 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 Progress Notes for CPT 90837
The Progress Notes format maps well to CPT documentation requirements when each section contains the required elements:
Session Summary
Document relevant information for this code's requirements.
Interventions
Document relevant information for this code's requirements.
Client Response
Document relevant information for this code's requirements.
Plan Updates
Document relevant information for this code's requirements.
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 Progress Notes for CPT 90837
Objective/Mental Status: Client arrived on time and was engaged throughout the full 60-minute psychotherapy session. Appearance was appropriate, speech was normal, mood was anxious, affect congruent, thought process linear, and no psychosis or suicidal ideation was reported. Insight and judgment were fair. Client participated actively in CBT interventions and grounding practice.
Assessment/Medical Necessity: Symptoms remain clinically significant and continue to impair occupational and interpersonal functioning. Therapeutic focus today addressed cognitive distortions, anxiety management, and emotion regulation in response to current stressors. Ongoing psychotherapy remains medically necessary to reduce symptom severity, improve coping skills, and support functional stability.
Plan: Continued weekly psychotherapy is recommended. Client will practice scheduled worry time, use breathing exercises twice daily, and track sleep and anxiety triggers before next session. Next session will continue CBT work related to workplace stress, boundaries, and behavioral activation.
Example only. Replace with session-specific details.
Documentation Considerations for Progress Notes for CPT 90837
Document Medical Necessity, Not Just Supportive Talk
For CPT 90837, the note should show why a 60-minute psychotherapy session was required. Payers expect more than a narrative of “checked in” or “provided support.” Link symptoms to functional impairment, such as sleep disruption, work problems, relationship conflict, or impaired self-care, and describe the active treatment provided. The record should make clear that the session was needed to address a diagnosable mental health condition and reduce clinically significant symptoms.
Time Must Support 60 Minutes of Psychotherapy
CPT 90837 is the 60-minute psychotherapy code and is typically reported when the face-to-face psychotherapy time is 53 minutes or more. Your progress note should clearly support that duration with a start/stop time or a total psychotherapy time statement if required by the payer or practice policy. Do not inflate time, and avoid ambiguity when other services occur during the visit. If the session was shorter, a different code may be more appropriate.
Pay Attention to Payer-Specific Documentation Rules
Some insurers require exact time notation, modality details for telehealth, and clear identification of the psychotherapy service separate from any assessment, medication management, or administrative tasks. A 90837 note should reflect the therapeutic interventions used, the patient’s response, and the treatment plan. If billing under telehealth, document the location of the client and clinician, platform used if required, and any payer-specific modifiers or place-of-service rules.
Audit Triggers Often Involve Overuse and Weak Detail
Common audit concerns for 90837 include frequent billing of the longer code without justification, repetitive or copied notes, vague statements like “client improving,” and lack of functional impairment. Auditors also look for notes that do not show active psychotherapy or that read like a brief check-in. Strong documentation should show the problem addressed, the therapeutic intervention, client response, and why a 60-minute session was clinically appropriate that day.
FAQ — Progress Notes for CPT 90837
When is CPT 90837 appropriate instead of 90834?
Use CPT 90837 when you provided psychotherapy for 53 minutes or more and the clinical needs of the session justify a full 60-minute service. The note should show a complex treatment focus, significant symptoms, or issues that required extended therapeutic work. If the session was shorter or the intervention was limited, 90834 is usually more appropriate. The documentation should clearly support the longer duration and the medical necessity for that length of treatment.
Do I need to include exact start and stop times in a 90837 progress note?
Not every payer requires exact start and stop times, but many auditors expect some clear time support for CPT 90837. Best practice is to document either the exact psychotherapy time or a start/stop time range that demonstrates at least 53 minutes of psychotherapy. Make sure the time reflects the actual psychotherapy portion, not time spent on paperwork, scheduling, or unrelated tasks. Follow the specific policy of the payer or your organization if it is stricter.
What elements should a 90837 progress note include to support billing?
A strong 90837 note should include the presenting problem, symptoms, functional impairment, psychotherapy interventions used, client response, and the treatment plan. It should also identify medical necessity by showing why the condition required ongoing psychotherapy. Include mental status information when relevant, but keep the emphasis on the active treatment provided during the 60-minute session. The note should read like a treatment document, not just a conversation summary.
What are the biggest documentation mistakes that lead to denials or audits?
The most common problems are billing 90837 too often without clear justification, failing to document 53+ minutes of psychotherapy, and using vague language that does not establish medical necessity. Other issues include cloned notes, lack of session focus, no evidence of therapeutic intervention, or records that look like medication management or a supportive check-in rather than psychotherapy. Clear time, a defined clinical issue, and specific interventions significantly reduce audit risk.
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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 mental health professionals.
- DSM-5-TR — Essential for accurate diagnosis documentation which supports progress notes and treatment planning.