CMS Documentation Requirements for Psychotherapy
What are CMS documentation requirements for psychotherapy?
Medicare pays for psychotherapy that is reasonable and necessary for the diagnosis or treatment of illness, and the note is the only proof it was. CMS expects each entry to show the date and duration of service, the diagnosis being treated, the specific therapeutic intervention delivered, the client's response, the plan for continued care, and a dated signature with credentials. Documented time must support the CPT code billed.
"Reasonable and necessary" is the entire standard
Section 1862(a)(1)(A) of the Social Security Act is the hook everything else hangs on: Medicare does not pay for services that are not reasonable and necessary for the diagnosis or treatment of illness or injury. Every documentation rule downstream exists so a reviewer can decide that question from the chart alone.
That framing tells you what a note is for. It is not a memory aid for you. It is evidence that a licensed clinician treated a diagnosed condition with an intervention appropriate to it, and that the client's condition warranted the service on that date. A note that would remind you what happened but would not convince a stranger is not a compliant note.
Two manuals matter. CMS Publication 100-02, the Medicare Benefit Policy Manual, sets out what is covered and under what conditions. CMS Publication 100-08, the Program Integrity Manual, tells contractors how to review what you submit. Neither is fun reading, but the second one describes how your chart will actually be judged, including the signature rules people lose claims over.
Time is the element auditors check first
Psychotherapy CPT codes are timed, and the time that counts is face-to-face time with the patient and, where applicable, family. Note writing, chart review, coordination calls, and no-show waiting do not count. If you habitually bill the code with the widest range you can defend, you will eventually meet someone who checks.
| Code | Service | Time the note must support | What draws scrutiny |
|---|---|---|---|
| 90791 | Psychiatric diagnostic evaluation | Untimed; document the full evaluation | A second unit in the same episode with no stated clinical reason |
| 90832 | Individual psychotherapy | 16 to 37 minutes | Rarely audited; commonly under-billed |
| 90834 | Individual psychotherapy | 38 to 52 minutes | The default for a standard hour |
| 90837 | Individual psychotherapy | 53 minutes or more | Highest scrutiny of any outpatient code; document why the length was needed |
| 90846 | Family psychotherapy, patient not present | 26 minutes or more | Notes that never name the identified patient's treatment goal |
| 90847 | Family psychotherapy, patient present | 26 minutes or more | Who attended, and why their participation was clinically necessary |
| 90853 | Group psychotherapy | Untimed by CPT; document start and stop plus group size | Identical notes for every group member on the same date |
| +90785 | Interactive complexity add-on | No time of its own | Appended to hard sessions rather than to a documented complicating factor |
Two habits protect you here. Record start and stop times rather than a rounded total, because a range removes any argument about which code the note supports. And when you bill 90837, put a sentence in the note explaining what consumed the extra time. A risk assessment, an exposure that needed a full habituation cycle, a couple's session that required separate individual time, a client in acute crisis. "The session ran long" is not a clinical rationale. "Extended time required to complete a suicide risk assessment and update the safety plan" is.
The elements a note has to carry
Regardless of your format, a Medicare-facing outpatient psychotherapy note should contain all of the following, and a reviewer will look for them roughly in this order:
- Date of service, with start and stop times or total face-to-face minutes.
- Place of service and modality, including the telehealth platform when applicable.
- The current ICD-10 diagnosis the service treats.
- The specific intervention delivered, named at the level of technique.
- The client's response, with data where data is possible.
- Risk assessment when clinically indicated, and what you did about the risk.
- The plan, including frequency and the next treatment plan review date.
- Your signature with credentials, and the date you signed.
Element four is where most notes fail, and element five is where the rest fail. Together they are what turns a session summary into a record of treatment. The connective tissue that links them to the diagnosis and the plan is the golden thread, and a reviewer follows it in exactly that order.
A 90837 note that holds, and one that does not
Client is a 41-year-old with major depressive disorder, recurrent, moderate (F33.1). Session ran 56 minutes on 08/17/2026.
Would not survive review: 55 min. Client continues to struggle with depression since losing her job. Processed feelings, provided support. Client feels heard. Continue weekly. — J.S.
That note fails on almost every axis. No start and stop times. No named intervention. No goal reference. No response you could measure. Nothing explaining why the session needed 53 minutes rather than 38. And initials are not a signature with credentials.
Would survive review: 08/17/2026, 3:02 to 3:58 p.m., 56 minutes face-to-face, individual psychotherapy, office. Dx F33.1. Client presented with worsened anhedonia and early-morning waking following termination from employment on 08/11. PHQ-9 today 16, up from 11 on 07/20. Addressed Goal 1 (increase weekly pleasant and mastery activities from 2 to 7 by 11/2026) using behavioral activation: reviewed activity log, identified two low-effort mastery tasks, scheduled both with specific days and times. Extended session time was required to complete a suicide risk assessment prompted by new passive ideation reported at open. C-SSRS screen positive for passive ideation, no plan, no intent, no access to means; protective factors include children at home and engagement in treatment. Safety plan reviewed and updated; crisis line entered into client's phone during session. Client engaged throughout and independently generated a third activity. Plan: continue weekly individual psychotherapy, daily activity log, PHQ-9 next session, safety plan review each session for four weeks, treatment plan review 09/2026. — Jordan Sable, LCSW, signed 08/17/2026.
The second note is longer, but the length is doing work. It explains its own duration in a single sentence, which is the sentence that keeps a 90837 claim.
Progress notes are not psychotherapy notes
People conflate these constantly, and the distinction is HIPAA's rather than CMS's. Under HIPAA, "psychotherapy notes" means your process notes: the ones analyzing the contents of a session, kept separate from the rest of the record, and requiring specific authorization to disclose.
The definition explicitly excludes medication prescription and monitoring, session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of diagnosis, functional status, treatment plan, symptoms, prognosis, and progress to date.
Read that exclusion list again. It is essentially the list of everything a payer wants. The protection does not shield your progress note from a records request. It shields a separate file, if you actually keep one separately. Two consequences follow: process notes only qualify if they are genuinely stored apart from the chart, and everything a payer needs has to live in the progress note, not in the protected file.
Signatures, late entries, and the LCD you actually have to read
Services must be authenticated by the author. Handwritten or valid electronic signatures are acceptable; stamps are not, except for an author with a documented physical disability. For review purposes, an unsigned note is not a note, no matter how good the content is. Your electronic record should capture who signed and when.
Late entries are permitted and they have to be labeled as such. A late entry carries the date you wrote it, identifies the date of service it documents, and is signed. An addendum adds new information to a signed note and is separately dated. A correction preserves the original, either as a strike-through that leaves the prior text readable or as an electronic amendment that retains the earlier version. Backdating is fraud. Rewriting a note after you receive a records request is worse than the original deficiency you were trying to fix.
Finally: most of what actually governs your notes lives with your Medicare Administrative Contractor, in a Local Coverage Determination and its associated billing and coding article, which you can find through the Medicare Coverage Database at cms.gov. Commercial payers layer their own manuals on top, and Medicaid varies by state. None of this is legal advice. Read your MAC's current LCD, your state Medicaid manual, and your payer contracts, because any of them can be stricter than the national rules.
Making the checks happen before you sign
Nearly every requirement above is machine-checkable at the moment you finish a note. Whether a current diagnosis is on file. Whether the note references an active treatment plan goal. Whether the documented minutes support the code about to go on the claim. Whether the plan expired last month. This is why Congruent runs a Golden Thread Check at signature time rather than leaving you to discover the gap in a records request two years later. It is included in both plans, at $20 per clinician per month for Solo and $29 for Practice, with no compliance add-on fee.
If you change one thing after reading this, put start and stop times in every note. It is the cheapest available protection for the code that draws the most scrutiny, and it costs about four seconds. Then go read your MAC's LCD. For what happens when the documentation does not hold up, see surviving a payer audit.