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Checklist: Psychotherapy services

This checklist is intended to provide health care providers with a reference for use when responding to medical documentation requests for psychotherapy services. Health care providers retain the responsibility to submit complete and accurate documentation.

Check Documentation description
  Documentation is for the correct beneficiary.
  Documentation contains a valid and legible signature, which follows CMS Signature Guidelines for Medical Review Purposes
  Documentation clearly identifies the person performing the service (including the title, education background, and credentials).
  Documentation clearly demonstrates session start and stop times and/or total time spent providing psychotherapy services to the beneficiary.
  Documentation demonstrates the telehealth method utilized during the service (e.g., audio / video), id applicable
  Documentation demonstrates the type of service being provided (including the therapeutic techniques and approaches, modalities, and frequencies of treatment furnished).
 

Documentation supports the medical necessity for psychotherapy treatment as evidenced by:

  • Maladaptive behavior that supports the need for ongoing psychotherapy treatment.
  • Results of clinical tests performed.
  • Medication prescription and monitoring (if applicable).
  • Summary of the diagnosis/symptoms, functional status, and treatment plan.
  • Frequency of treatment furnished, prognosis, and progress.
  Documentation to support "incident to" guidelines (if applicable), that includes evidence of billing provider's presence in the office suite and ongoing participation in patient care.
  For services that include an evaluation and management (E/M) component, the E/M services should be documented.
  If applicable and required, submitted documentation should include a beneficiary waiver of liability. 

 

Disclaimer

This checklist was created as an aid to assist providers. This aid is not intended as a replacement for the documentation requirements published in national or local coverage determinations, or the CMS documentation guidelines. It is the responsibility of the provider of services to ensure the correct, complete, and thorough submission of documentation.