Clinical Guide: Psychotherapy Documentation and Code Selection
Help Therapy manages claim submission, but the treating provider selects and documents services accurately. Choose codes for the service actually performed, the patient’s needs, your license and payer rules. This guide is a starting point; payer policies and documentation requirements vary. Ask billing@helptherapy.com before billing an unfamiliar combination.
Initial assessment (90791)
Help Therapy’s usual workflow begins with a documented diagnostic evaluation before routine psychotherapy. Record the clinical history, assessment, diagnosis or supported provisional diagnosis, and care plan appropriate to the visit. Do not assume a universal six-month rule for repeating 90791; a new evaluation requires clinical justification and payer review. Acute crisis care may call for crisis services instead of a routine intake.
Individual psychotherapy
Select 90832 for 16–37 minutes, 90834 for 38–52 minutes, or 90837 for 53 or more minutes of psychotherapy under the applicable payer policy. Document the actual duration, interventions, patient response, and progress or changes in the plan. A longer scheduled appointment alone does not justify a longer code.
Family and crisis services
Codes 90846 and 90847 describe family psychotherapy without and with the identified patient, respectively. Document participants, the identified patient’s treatment purpose, and payer coverage. Codes 90839 and add-on 90840 are for qualifying crisis psychotherapy; document the crisis, risk assessment, interventions, safety planning, and actual time. Confirm thresholds and any payer-specific rules with billing before selecting add-on units.
Brief assessments and interactive complexity
Code 96127 may apply to a brief standardized behavioral assessment when the instrument is administered, scored, and documented and the payer allows it. Record the tool, score, clinical interpretation, and action. Follow the applicable referral and payer requirements for timing and frequency. Do not add 90785 solely because an interpreter, play materials, or a family member was present. It requires a qualifying communication factor and documentation under the payer’s rules.
Missed visits are not psychotherapy claims. Record the actual attendance status and follow the client’s signed financial policy; VA/TriWest veterans must not be charged a no-show fee. Direct coding and billing questions to billing@helptherapy.com. Medicare psychotherapy time guidance: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=57520