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90836 Documentation Made Simple: Best Practices That Save Time and Ensure Compliance

Stanley Efrem

Mar 27, 2025

Medicare Part B made $580 million in improper payments for psychotherapy services in the first year of COVID-19 pandemic. Documentation errors emerged as the biggest problem. The CPT code 90836, which covers psychotherapy sessions with E/M services, creates significant compliance challenges.

Your 90836 documentation must capture the exact 38-52 minute time range and separate E/M services from psychotherapy clearly. The American Medical Association specifies this code with 45 minutes of patient interaction when performed among E/M services. The OIG discovered that more than half of their sampled cases failed to meet simple documentation standards.

This detailed guide shows you the documentation requirements for 90836. You'll learn to avoid common mistakes and stay compliant while making your workflow more efficient.

Common 90836 CPT Code Documentation Mistakes

Providers often face compliance issues and denied claims due to documentation errors with the 90836 CPT code. Medicare audits show common mistakes that keep appearing when providers bill these 45-minute psychotherapy sessions with evaluation and management components.

Failing to document the specific time range

The 90836 CPT code needs 38-52 minutes of psychotherapy time. Medicare guidelines clearly state that providers must document start and stop times (or total time) for these time-based codes [1]. Many providers skip this vital information or write down just one time period that doesn't separate psychotherapy from E/M components.

Providers also make the mistake of including E/M activities time in their psychotherapy minutes calculations. Only the time devoted to psychotherapy counts toward the 38-52 minute requirement for 90836 [2]. Your documentation should show "the time spent providing face-to-face psychotherapy" [3] as a service distinct from others.

Blurring E/M and psychotherapy services

CPT guidelines state that "To report both E/M and psychotherapy, the two services must be significant and separately identifiable" [3]. Audits reveal that documentation often doesn't separate these services.

Medical records need to show two distinct services during the encounter. A Medicare document points out that "many psychiatric providers offer both evaluation and management services and psychotherapy in the same session but often fail to document them separately" [4].

E/M services focus on medication adjustments and symptom evaluation. Psychotherapy involves structured therapeutic interventions. Payers might assume the psychotherapy was part of the E/M service if your notes don't make this clear distinction, which leads to denied claims [4].

Missing essential clinical elements

Providers skip required clinical elements in their 90836 documentation. Your records must include:

Measurable goals in the treatment plan (not templated statements carried over between sessions) [5]
Documentation of the patient's progress toward these goals [1]
Details about the therapy intervention techniques you employ [3]
The patient's functional status and response to treatment [3]

Treatment plans should be unique to each patient with specific, measurable goals [5]. Medicare needs regular updates to treatment plans. This is crucial for "prolonged periods of psychotherapy," which "must be well-supported in the medical record describing the necessity for ongoing treatment" [6].

Mastering Time Documentation for 90836

Accurate time documentation is the life-blood of compliant 90836 billing. Psychotherapy with E/M services needs careful tracking of separate activities. A proper understanding of time documentation methods can reduce denials and audit risks by a lot.

Start and stop time vs. total time approaches

Medicare accepts two methods to document the time component of 90836 services. You can record the specific start and stop times (e.g., "Psychotherapy began at 2:15 pm and ended at 3:00 pm") or note the total time spent (e.g., "45 minutes of psychotherapy provided") [7]. Both approaches need clear separation of psychotherapy time from E/M activities in combined sessions, as "the total time does not include the E/M time" [7].

Ensuring the 38-52 minute requirement is met

The 90836 CPT code covers psychotherapy sessions that last 38-52 minutes when performed with an E/M service [8]. Your documentation must show enough time spent on psychotherapy to support this code. Here are the essential requirements:

Pick the code closest to actual time spent (38-52 minutes for 90836) [7]
Never bill for psychotherapy that lasts less than 16 minutes [9]
Document only face-to-face psychotherapy time [9]
Time spent on E/M activities doesn't count toward psychotherapy time [10]

Documentation language that clearly separates E/M time

CMS identifies "blending of time periods" as a common billing error [11]. So your documentation should clearly separate these two services. To name just one example, see this format: "Total encounter time: 60 minutes. 15 minutes spent on medication management and symptom evaluation. 45 minutes devoted to cognitive behavioral therapy focusing on anxiety management techniques."

This clear separation matters because "time spent performing E/M services cannot be counted toward the time requirement for psychotherapy services or vice versa" [12]. On top of that, it's worth noting that psychotherapy time "may not be continuous in a combined psychotherapy with an E/M service" [7]. Make sure to track all segments spent on therapeutic intervention accurately.

Creating Audit-Proof Treatment Plans

Treatment plans are the life-blood of your 90836 CPT code documentation. Medicare Administrative Contractors (MACs) now scrutinize these plans through Targeted Probe and Education audits [13]. Your documentation needs to exceed simple requirements to create truly audit-proof records.

Measurable goals that satisfy documentation requirements

Medicare requires treatment plans to contain measurable, objective goals instead of vague statements. Documentation protocols mandate that each goal must be:

Patient-specific (not templated across multiple patients) [5]
Time-framed with clear endpoints [14]
Directly related to the admission reason [14]
Functional and demonstrable [14]

To cite an instance, see how "Patient will reduce anxiety" becomes "Patient will reduce anxiety attacks to 2 per week by using techniques learned in sessions over 3 months" [5]. This approach meets Medicare's requirement for precise, quantifiable objectives.

Documenting patient progress effectively

You must track and document progress systematically for each 90836 session, beyond just setting goals. Your notes should include:

The patient's therapeutic intervention response [13] Assessment of functional status changes [15] Documentation of ongoing symptom presentation [15] Links between current progress and treatment goals [14]

Each progress note needs your signature, date, credentials, and must be legible [16]. Your progress documentation should focus on specific behavioral changes that link to your measurable objectives rather than general observations.

Updating treatment plans appropriately

Treatment plans evolve with time. Medicare expects you to review and refresh these plans every three months [17]. The plans also need updates when clinical conditions change by a lot, such as medication adjustments [14].

Your updates must include a detailed reevaluation of goals, progress toward these goals, and treatment approach modifications [13]. This ongoing documentation creates a continuous record that shows medical necessity—the foundation of defending your 90836 billing during audits.

Technology Tools That Improve 90836 Documentation

Technology plays a vital role in helping mental health providers deal with their documentation workload. A 2020 study revealed that physicians dedicate 16 minutes and 14 seconds per patient encounter to EHR use. Documentation takes up 24% of this time [18]. This administrative burden affects patient care and leaves clinicians with little time to interact meaningfully with patients.

EHR features that boost compliance

Modern EHR systems come with specialized features to make 90836 documentation easier. The best platforms offer customizable templates that adapt when compliance requirements change. This helps prevent errors that can get pricey [19]. Quality EHRs should have built-in time tracking tools to document the critical 38-52 minute requirement for 90836 services accurately.

On top of that, complete reporting capabilities let your practice track compliance initiatives and spot documentation gaps before they become audit problems [19]. Some systems let auditors access EHRs under supervision, which makes the review process much simpler [19].

Mobile documentation options for busy providers

Mobile documentation solutions have become crucial now that telehealth services for mental health are reimbursable through December 31, 2024 [20]. These platforms let providers document their work immediately after sessions, whatever their location.

Patient portals that combine smoothly with billing systems can boost collection rates while making communication better. Automated claim scrubbing tools check if your 90836 documentation meets payer requirements before submission, which reduces rejections.

Voice-to-text solutions for faster documentation

Voice recognition software has become a powerful tool to create 90836 documentation. These systems understand up to 200 words per minute—matching normal conversation speed—which makes them much more efficient than typing [22].

Physicians who use speech recognition technology save 5 minutes on each clinical document [23]. This efficiency boost lets providers see up to one-third more patients over time [22]. The systems learn specialized psychiatric terminology and become more accurate as providers use them regularly [23].

Medical-specific speech recognition software works better than consumer-grade products because it understands complex psychiatric terms [24]. Dragon® NaturallySpeaking® Medical Edition stands out as a soaring win, with over 70,000 clinicians using it [25].

Conclusion

Documentation for CPT code 90836 is easier than you might think. You can handle it well with the right approach. Your success relies on three basics: tracking time accurately, keeping E/M and psychotherapy services separate, and creating detailed treatment plans with clear goals.

Modern technology gives you practical tools to tackle these documentation tasks. You'll find speech recognition software, specialized EHR features, and mobile documentation apps that help you stay compliant. These tools cut down your paperwork time so you can focus more on patient care.

Note that solid documentation protects you during audits and prevents claim denials. Your progress notes should paint the full picture - from specific time periods to therapeutic methods used. They must show how patients progress toward their goals. This approach will give you a smoother workflow and keep your practice compliant.

FAQs

How should I properly document time for CPT code 90836?

To document time for 90836, record either specific start and stop times or the total time spent on psychotherapy. Ensure you clearly separate the 38-52 minutes of psychotherapy time from any E/M activities. Only face-to-face psychotherapy time counts towards this requirement.

What are the key elements of a compliant treatment plan for 90836 billing?

A compliant treatment plan should include specific, measurable goals tailored to the patient. These goals should be time-framed, directly related to the reason for treatment, and demonstrate functional outcomes. Regularly document patient progress towards these goals and update the plan as needed, typically every three months.

How can I differentiate between E/M and psychotherapy services in my documentation?

Clearly separate E/M and psychotherapy services in your notes. For example, state "15 minutes spent on medication management, followed by 45 minutes of cognitive behavioral therapy." This distinction is crucial as time spent on E/M cannot count towards psychotherapy time and vice versa.

What technology tools can help improve 90836 documentation efficiency?

EHR systems with customizable templates and built-in time tracking can streamline 90836 documentation. Mobile documentation options allow for real-time note-taking during or immediately after sessions. Voice-to-text solutions, especially medical-specific ones like Dragon® NaturallySpeaking® Medical Edition, can significantly speed up the documentation process.

What are common documentation mistakes to avoid when billing 90836?

Common mistakes include failing to document specific time ranges, blurring E/M and psychotherapy services, and omitting essential clinical elements. Avoid using generic templates for treatment plans, ensure you're meeting the 38-52 minute requirement for psychotherapy, and always include measurable goals and progress updates in your documentation.