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October 2025 Top of Mind

Avoid the top 3 errors when submitting psychotherapy or E/M medical records

Are you submitting claims for any of the following CPT codes?

Psychotherapy codes and session times

  • 90382: 30 minutes
  • 90834: 45 minutes
  • 90837: 60+ minutes

Evaluation and Management (E/M) service codes and session times

New Outpatients

  • 99202: 15-29 minutes
  • 99203: 30-44 minutes
  • 99204: 45-59 minutes
  • 99205: 60-74 minutes

Established Outpatients

  • 99211: Time component removed
  • 99212: 10-19 minutes
  • 99213: 20-29 minutes
  • 99214: 30-39 minutes
  • 99215: 40-54 minutes

Psychotherapy add on codes and session times

  • 90833: 16-37 minutes
  • 90836: 38-52 minutes
  • 90838: 53+ minutes

Checking the three most common errors when submitting medical records for Psychotherapy, Evaluation and Management (E/M) and psychotherapy add-on services may help prevent claim denial and ensure prompt payment.

3 things to include in your session documentation

  1. Is information missing or incorrect? Verify you included signature, credentials and start/stop times. Check that the session time matches the code requirements. If the patient’s family was present and part of the therapy session, consider a family therapy code.
  2. Did you meet the Medical Decision Making (MDM) requirements for the E/M code billed? Did you bill at a higher level, but only meet the requirements for the lower level? It’s common to bill at a higher E/M based on time.
  3. Are the services listed separately? Please ensure psychotherapy is documented distinctly from the E/M service, and that you document the entire session (psychotherapy + E/M therapy).

Additional resources

Please consult the following resources for additional guidance on submitting E/M and psychotherapy-related medical records:


 

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