Documentation requirements in mental health shift frequently. Between CMS updates, payer-specific rules, and state regulations, what worked last year may not satisfy auditors this year.
Progress notes vs. psychotherapy notes
Before anything else, understand this fundamental distinction. It determines what goes where and who can see it.
Progress notes are part of the medical record. They document the service provided and must be available to other providers, payers, and (with exceptions) the patient. These notes support medical necessity and are what auditors review.
Psychotherapy notes (or "process notes") are separate, private records containing your personal impressions, theoretical analyses, and detailed session content unnecessary for treatment continuity: your hypotheses about dynamics, emotional reactions to the session, theoretical interpretations. HIPAA gives these extra protection: they can't be released without specific patient authorization, even to other healthcare providers or insurers.
The critical rule: keep psychotherapy notes physically and electronically separate from progress notes. Never store them in the main medical record.
What progress notes must contain
Whatever format you use (SOAP, DAP, BIRP) your notes need these elements:
Client presentation. How the patient appeared: affect and mood, behavior, mental status observations, safety concerns. This establishes clinical context.
Subjective report. What the patient told you: current symptoms and severity, events since last session, response to interventions, new stressors. Summarize rather than transcribe.
Interventions used. What you did: specific therapeutic techniques (cognitive restructuring, exposure work, skills practice), topics addressed, homework reviewed. "Provided supportive therapy" doesn't demonstrate medical necessity. Be specific.
Client response. How the patient responded: engagement, insights, resistance, skill acquisition. This shows whether treatment is working.
Assessment. Your clinical judgment: progress toward goals, symptom changes, risk assessment. Link assessment to objective observations and the patient's report.
Plan. Next steps: interventions planned, homework assigned, follow-up timeline, referrals needed.
Time-based billing documentation
Mental health billing codes are time-based. Documentation must support the time billed.
| CPT Code | Service | Time Range |
|---|---|---|
| 90832 | Individual psychotherapy | 16-37 minutes |
| 90834 | Individual psychotherapy | 38-52 minutes |
| 90837 | Individual psychotherapy | 53+ minutes |
| 90846 | Family therapy without patient | 50 minutes |
| 90847 | Family therapy with patient | 50 minutes |
| 90853 | Group therapy | Variable |
Time that counts: face-to-face therapy with the patient, time with family members when the patient is present (for 90847).
Time that typically doesn't count: documentation, phone calls to coordinate care, reviewing records, travel.
If you bill 90837, your note should reflect content consistent with 53+ minutes. Auditors flag notes that are too brief for time billed, contain boilerplate language, or show patterns of always billing the highest code.
2026 CMS changes
CMS has removed time-based documentation requirements for behavioral health integration (BHI) and collaborative care management (CoCM) codes, acknowledging that rigid time tracking interferes with clinical care. However, for standard psychotherapy codes (90832, 90834, 90837), time-based requirements remain unchanged.
Treatment plan requirements
Treatment plans establish the framework for ongoing care. Payers look for plans that are individualized, based on assessment findings, containing measurable goals, and updated regularly.
Required elements:
- Current DSM-5-TR diagnosis with supporting information
- Specific symptoms and functional impairments being addressed
- Goals that are specific, measurable, achievable, and time-bound ("reduce PHQ-9 score below 10" rather than "feel better")
- Objectives as smaller steps toward each goal
- Interventions you'll use
- Session frequency and estimated treatment duration
Most standards require updates every 30-90 days, or when the patient's condition changes significantly, treatment goals are met or revised, or treatment approach changes. Document the review even if nothing changes: "Treatment plan reviewed [date]. Patient progressing toward goals. Plan continues as written."
Using standardized assessments
Validated assessments like the PHQ-9 and GAD-7 strengthen documentation considerably. A note stating "PHQ-9 decreased from 18 to 12, indicating partial response to treatment" is far stronger than "patient reports feeling somewhat better."
Document: assessment name and version, date administered, score and interpretation, comparison to previous scores, how results inform treatment.
Assessments provide objective baselines for severity, measurable outcomes for treatment plans, evidence of medical necessity, support for level-of-care decisions, and defense against audit challenges.
Telehealth documentation in 2026
Telehealth sessions require standard progress note content plus:
- That service was provided via telehealth
- Technology platform used
- Patient location (state) at time of service
- Any technology issues affecting the session
New for 2026: After January 30, 2026, Medicare requires an in-person visit within 6 months prior to the first mental health telehealth service for new patients. Established patients (those who began receiving services on or before January 30, 2026) need at least one in-person visit every 12 months, though an exception exists when both provider and patient agree that risks or burdens of in-person care outweigh benefits. Document the reasons for any exception in the medical record.
Audio-only services after January 30, 2026 require that you're capable of audio-video technology and that the patient either can't use or doesn't consent to video. Document this.
Signature and timing
Complete notes within 24-48 hours. Late documentation is less accurate, raises audit flags, and can result in denials.
Use full credentials, include date of signature, and note that the signature date may differ from service date. Once signed, never alter the original. Add a dated addendum if changes are needed.
EHR pitfalls
Electronic records help with compliance but create specific risks:
Copy-forward abuse. Templates are fine. Copying yesterday's note with minimal changes is not. Cloned notes, documentation that looks identical across visits, signal that notes don't reflect actual care.
Auto-populate errors. Review any automatically filled information. Yesterday's mental status exam shouldn't appear in today's note without verification.
Time stamps. Notes created days after the session should show creation date, not be backdated to service date.
Audit-ready documentation
Write every note as if an auditor will read it:
- Complete: all required elements present
- Accurate: reflects what actually happened
- Timely: written close to service date
- Individualized: obviously specific to this patient and session
- Consistent: diagnosis, symptoms, treatment, and goals align logically
- Supported: claims backed by note content
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Documentation that clearly connects diagnosis, symptoms, treatment, and expected outcomes rarely gets denied for lack of medical necessity. The investment in thorough notes pays off in fewer audit headaches and faster reimbursement.