Documentation for CPT code 90837 (Psychotherapy, 53+ minutes) must meet specific time and complexity requirements while capturing essential clinical information. Using the SIRP Notes format for 90837 billing requires understanding how this note structure aligns with CPT documentation requirements.
SIRP 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 SIRP 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 SIRP Notes for CPT 90837
The SIRP Notes format maps well to CPT documentation requirements when each section contains the required elements:
Situation
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 SIRP Notes for CPT 90837
Intervention: Therapist used CBT-based interventions to identify automatic thoughts, challenge catastrophic thinking, and rehearse grounding skills. Therapist also provided supportive psychotherapy to reinforce coping efforts, reviewed sleep hygiene strategies, and collaborated with the client on a brief exposure plan for attending the next team meeting.
Response: Client was engaged, tearful at times, and able to identify the link between avoidance and increased anxiety. They practiced diaphragmatic breathing in session and reported a modest reduction in distress by the end of the visit, rating anxiety as 6/10 at start and 4/10 at close. Client verbalized understanding of homework and agreed to track triggers and responses before the next session.
Plan: Continue weekly psychotherapy at 90837 level due to symptom severity, functional impairment, and need for extended 53+ minute treatment time. Client will practice grounding twice daily, complete thought record worksheets, and attend the next appointment in one week to assess symptom change, coping use, and readiness to increase behavioral activation.
Example only. Replace with session-specific details.
Documentation Considerations for SIRP Notes for CPT 90837
Document Why 90837-Level Time Was Medically Necessary
CPT 90837 supports psychotherapy lasting 60 minutes with approximately 53 minutes or more of face-to-face psychotherapy time. The note should clearly show why the extended session was needed, such as symptom severity, crisis-like distress, complex trauma work, significant functional impairment, or the need for in-session skill practice and stabilization. Avoid implying that a long visit was chosen for convenience or scheduling; the record should tie the duration directly to treatment necessity.
Time Documentation Must Match the Code
For 90837, payers commonly expect explicit time support somewhere in the note or billing workflow. If using time-based documentation, record the start and stop time or total psychotherapy minutes, and ensure the total reaches the payer’s threshold for 90837. A vague statement like “extended session” is not enough. The documentation should make it easy to verify that psychotherapy, not administrative time, accounted for the billed duration.
Watch Payer Rules on Telehealth and Modifiers
Some payers require specific telehealth modifiers, place-of-service codes, or audio-video documentation for 90837 claims. SIRP notes should reflect the modality used, such as in-person or telehealth, and confirm that psychotherapy was delivered to the patient individually. If the payer has stricter requirements for prolonged therapy claims, align the note with those rules so the session description, duration, and setting all support clean claim submission.
Common Audit Triggers Include Weak Medical Necessity and Copy-Paste Notes
Auditors often flag 90837 when notes look generic, repetitive, or identical across sessions. Missing linkage between the patient’s symptoms, treatment interventions, and response is a frequent problem. Another trigger is billing 90837 repeatedly without showing ongoing severity, complexity, or measurable clinical need. Keep the SIRP narrative specific to the encounter, and make clear how the extended time was used therapeutically rather than simply adding words.
FAQ — SIRP Notes for CPT 90837
What should a SIRP note include to support CPT 90837?
A SIRP note for CPT 90837 should clearly document the patient’s current clinical situation, the psychotherapy interventions used, the patient’s response, and the follow-up plan. Because 90837 is the 60-minute psychotherapy code, the note should also support that the session required approximately 53 minutes or more of psychotherapy time. The content needs to show medical necessity, not just that the session was long. Include symptoms, functional impact, therapeutic techniques, and why the extended session was appropriate.
Do I need to record exact start and stop times for 90837?
Many payers strongly prefer exact start and stop times or a clearly documented total psychotherapy duration because 90837 is time-based and typically requires 53 minutes or more. Even when not explicitly required in every policy, exact times make the note easier to defend during an audit. If you document total time, make sure it reflects only psychotherapy time and not charting, scheduling, or other non-therapeutic activity. The documented time should match the billed code.
How do I show medical necessity in a 90837 SIRP note?
Medical necessity is shown by tying the patient’s symptoms to functional impairment and to the level of intervention needed in the session. For example, document severe anxiety, trauma symptoms, suicidal risk assessment, significant avoidance, interpersonal instability, or inability to cope without extended therapeutic processing. Then explain how the longer session was used for clinically necessary work such as de-escalation, cognitive restructuring, exposure planning, or safety stabilization. The note should make clear why a shorter visit would not have been sufficient.
What are the biggest documentation mistakes that cause 90837 denials or audits?
Common mistakes include documenting too little detail about the clinical issue, failing to support the time requirement, and using the same templated language for every session. Payers may also deny or audit claims when notes do not show why the session needed to be 53+ minutes, when the intervention described is too vague, or when the therapy content appears minimal despite billing 90837. Make each note encounter-specific and ensure the narrative matches the billed duration and psychotherapy scope.
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Further Reading
- CMS Documentation Requirements — Provides official guidelines on documentation standards required for billing CPT codes including 90837.
- APA Documentation Guidelines — Offers detailed best practices for clinical documentation relevant to psychotherapy notes.
- HHS HIPAA — Covers privacy and security rules essential for maintaining confidentiality in psychotherapy documentation.