Documentation for CPT code 90837 (Psychotherapy, 53+ minutes) must meet specific time and complexity requirements while capturing essential clinical information. Using the SOAP Notes format for 90837 billing requires understanding how this note structure aligns with CPT documentation requirements.
SOAP 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 SOAP 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 SOAP Notes for CPT 90837
The SOAP Notes format maps well to CPT documentation requirements when each section contains the required elements:
Subjective
Include the client's presenting concerns, history of present illness, relevant background, current symptoms, and functional impact. This section should address "why is the client here today?" and establish medical necessity for services.
Objective
Document observable findings, behavioral observations, mental status examination findings, vital signs if relevant, and any objective measures or assessment tools administered.
Assessment
Provide your clinical interpretation, diagnostic assessment with DSM-5 codes, risk assessment findings, and your clinical impression of the client's current status and progress.
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 SOAP Notes for CPT 90837
O: Appearance neat but fatigued; affect constricted and congruent with reported mood. Speech normal rate and volume. Thought process linear and goal-directed. Oriented x4. No psychosis observed. Interventions included CBT focused on identifying automatic thoughts, behavioral activation planning, and coping-skills rehearsal. Client participated actively, completed in-session thought record, and demonstrated ability to generate two alternative balanced thoughts.
A: Symptoms remain clinically significant and continue to impair sleep, concentration, and occupational functioning. Progress is modest; client showed improved insight into the link between conflict-triggered thoughts and nighttime rumination, but depressive symptoms persist. Ongoing weekly psychotherapy remains medically necessary to reduce symptom severity, improve functioning, and address relapse risk. Risk level assessed as low today based on denial of SI/HI and presence of future-oriented goals.
P: Continue individual psychotherapy, CPT 90837, for 60 minutes next week. Client will practice paced breathing twice daily, complete one behavioral activation task before next session, and use the thought record to monitor rumination episodes. Therapist will continue CBT targeting cognitive distortions, sleep-disrupting routines, and avoidance behaviors; reassess mood, sleep, and safety at follow-up.
Example only. Replace with session-specific details.
Documentation Considerations for SOAP Notes for CPT 90837
Document Medical Necessity, Not Just Supportive Counseling
CPT 90837 requires psychotherapy that is medically necessary for a diagnosed mental disorder, not a general life-coaching or supportive conversation. Your note should link symptoms to functional impairment, such as disrupted sleep, work performance, relationships, or daily self-care. State why a 60-minute psychotherapy session was needed to address the severity, complexity, or acuity of the presentation.
Time Must Support the 60-Minute Psychotherapy Code
90837 is a time-based code for 60 minutes of psychotherapy, typically representing 53 minutes or more of face-to-face psychotherapy time. Document the actual psychotherapy time clearly in the note or appointment record, and make sure the time aligns with the service billed. Avoid vague phrases like “long session” or documenting non-billable activities as psychotherapy time.
Check Payer Rules Before Billing 90837
Many payers scrutinize 90837 more closely than shorter psychotherapy codes and may require specific wording, prior authorization, or diagnoses that meet their medical-necessity criteria. Some plans request session timing, modality, and treatment goals in a certain format. Verify telehealth rules, modifiers, and whether the payer expects a narrative showing why 60 minutes was required instead of 45–50 minutes.
Common Audit Triggers Include Weak Time and Mismatch Issues
Auditors often flag 90837 when the note looks identical to shorter sessions, lacks a clear treatment plan, or does not justify prolonged psychotherapy. Other red flags include missing time documentation, inconsistent start/stop times, overuse of 90837 for every visit, and notes that describe extensive testing, case management, or medication management instead of psychotherapy. Keep the record specific, symptom-focused, and internally consistent.
FAQ — SOAP Notes for CPT 90837
What should I document in a SOAP note to support CPT 90837?
Include the presenting symptoms, the specific functional impairments they cause, the psychotherapy interventions used, the patient’s response, and a plan tied to the diagnosis. For 90837, also document the actual psychotherapy time and make clear why a 60-minute session was medically necessary. The note should show that the visit was psychotherapy, not just supportive counseling, check-in, or administrative discussion.
How detailed does the time documentation need to be for 90837?
It should be precise enough to prove that at least 53 minutes of psychotherapy were provided, since 90837 is the 60-minute psychotherapy code. Best practice is to record the exact duration or start/stop times in a way that matches the billed service. If your practice uses total session time, ensure the note and billing policy clearly define that the documented time reflects psychotherapy time only.
Can I bill CPT 90837 if the session included some non-psychotherapy topics?
Yes, but only the psychotherapy portion counts toward 90837. If the visit includes brief administrative, scheduling, or care-coordination discussion, separate those from the psychotherapy time in your documentation and billing practices. The majority of the billed time must reflect psychotherapy. If the session was primarily medication management, case management, or crisis triage, another code may be more appropriate.
Why do payers audit 90837 more often than other psychotherapy codes?
Because 90837 is longer and reimburses more, payers often look for patterns suggesting overuse or inadequate medical-necessity support. They may compare it with 90834 frequency, diagnosis severity, and treatment progress. Notes that lack time documentation, repeat the same language every week, or fail to show functional impairment are common audit targets. Clear, individualized documentation reduces denials and recoupment risk.
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Further Reading
- CMS Documentation Requirements — Provides official guidelines on documentation standards required for Medicare billing, including psychotherapy services.
- APA Documentation Guidelines — Offers detailed recommendations on clinical documentation practices relevant to psychotherapy and mental health services.
- HHS HIPAA — Outlines privacy and security rules essential for compliant mental health documentation and patient record handling.