What CPT codes are used for psychotherapy sessions?

Time-based codes: 90832 (16-37 min), 90834 (38-52 min), 90837 (53+ min) for individual therapy. Family therapy: 90846 (without patient), 90847 (with patient). Group therapy: 90853. Add interactive complexity (90785) when needed. Document actual face-to-face time; don't include documentation time. Most insurers require 38+ minutes for 90834.

What session documentation is required for therapy billing?

Document: session focus (presenting concerns addressed), interventions used (specific techniques, not just modality), patient response to interventions, progress toward treatment goals, risk assessment update, homework assigned, and treatment plan. Documentation should demonstrate skilled therapy intervention. Generic notes ('discussed feelings') are insufficient.

How should therapeutic interventions be documented?

Document specific interventions: 'Used Socratic questioning to challenge cognitive distortion about worthlessness' (CBT), 'Practiced distress tolerance skills (TIPP)' (DBT), 'Explored transference related to authority figures' (psychodynamic). Include patient's response to intervention and homework assigned. Specificity demonstrates medical necessity.

What progress documentation is needed for therapy sessions?

Document: treatment goals established, progress toward each goal (improved, stable, declined), specific evidence of progress (behavioral examples, symptom changes, skill acquisition), and barriers to progress if applicable. Include comparison to initial presentation. Progress documentation supports continued treatment authorization.

How do I document risk assessment in therapy notes?

Document: assessment of suicidal ideation (asked directly), homicidal ideation, and self-harm urges at every session. Include risk level, protective factors, and safety plan status. Even brief notation ('Patient denies SI/HI') documents assessment occurred. More detailed documentation required when risk is elevated. Update safety plan when indicated.

Therapy Session Note Template - Psychotherapy Documentation

Psychiatry — Therapy Session Note Template

Psychiatry Psychiatry Updated: 11/7/2025

The Therapy Session Note Template is designed for mental health providers conducting psychotherapy sessions including cognitive behavioral therapy (CBT), dialectical behavior therapy (DBT), psychodynamic therapy, supportive therapy, and other therapeutic modalities. This template efficiently documents session content, therapeutic interventions, patient progress, treatment goals, and treatment plan adjustments while maintaining appropriate detail for billing and clinical documentation. The template supports billing for psychotherapy services (CPT 90834, 90837, 90847 for family therapy, 90853 for group therapy) and includes sections for session type and modality, presenting concerns and session focus, therapeutic interventions used, patient response and engagement, progress toward treatment goals, homework assignments or between-session tasks, risk assessment updates, treatment plan modifications, and scheduling of next session. This template balances thorough clinical documentation with efficiency for high-volume therapy practices. Ideal for outpatient mental health clinics, private practice therapists, integrated behavioral health programs, and community mental health centers providing psychotherapy services.

Session Information

Session type: Individual / Family / Group / Couples
Modality: CBT / DBT / Psychodynamic / Supportive / Other: [specify]
Session duration: [minutes]
Session number: [X] of planned [Y] sessions

Presenting Concerns / Session Focus

Main topics discussed, patient's stated concerns, session agenda.

Therapeutic Interventions

Interventions used: Cognitive restructuring, behavioral activation, exposure, skills training, validation, interpretation, psychoeducation, etc.
Specific techniques applied and rationale.

Patient Response

Engagement level, emotional response, insight gained, resistance or barriers, homework completion from previous session.

Progress Toward Treatment Goals

Goal: [Specific treatment goal]
Progress: Improved / Stable / Needs attention
Evidence of progress: [Specific examples]

Risk Assessment

Suicidal ideation: None / Passive / Active (document details if present)
Homicidal ideation: None / Present (document details if present)
Self-harm: None / Present (document details if present)
Safety planning: Completed / Not indicated

Homework / Between-Session Tasks

Assignments given: [Specific tasks]
Rationale: [Why these assignments support treatment goals]

Treatment Plan

Continue current approach / Modify interventions / Adjust frequency / Consider medication evaluation / Refer for additional services.

Next Session

Scheduled: [Date/time]
Focus: [Planned focus for next session]