As we know, selecting the correct CPT code for psychotherapy has a great deal to do with time. The question is, how should we document that time?
There used to be a discussion regarding whether to document “duration” or actual Start and Stop Time. Several States have helped settle this argument by requiring documenting the Start and Stop time for at least Medicaid/Medicare covered services. Most insurance companies will encourage use of the Start and Stop times in their documentation standards. Some simply require it. So, the safe bet is to document the Start and Stop times in your progress notes.
But what should that actually look like?
While EHR applications can document a start and stop time for psychotherapy progress notes, in some cases those times are loaded as general numbers to represent the CPT Code used.
For purposes of representing your session time, this is not a great way to document time.
The expectation is that the Start and Stop Time represents the actual face-to-face therapy time with the client.
So, wherever possible, either modify what the EHR automatically provides or make sure to include an actual start and stop time in the note, as early in the note as possible.
This does bring up another question – what do we do with the family/conjoint therapy 90846/7 codes? While technically these codes are not “timed” codes, there is a minimum threshold of 26 minutes. So, I always encourage following the same Start and Stop time standards for these codes as I do with individual psychotherapy.
That way it’s clear.