Therapy notes that document what insurers look for
Payers expect each note to show medical necessity, the time and service billed, the interventions used and progress toward goals. My Clinical Writer drafts notes from templates that prompt for those elements, and you review them before they go anywhere.
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What payers generally look for in a therapy note
Most documentation problems come down to a missing element rather than a clinical one. Payer policies differ, but these elements come up again and again:
Medical necessity
The note should justify why therapy is medically necessary: a clearly stated diagnosis, documented functional impairment, a link between the symptoms and the treatment, and progress toward goals.
Accurate time
Psychotherapy codes are time-based. Record the start and stop times or the total face-to-face time, and make sure it matches the code billed.
Treatment plan elements
Specific treatment goals, measurable progress indicators, interventions that match the goals, and periodic updates to the plan.
Risk assessment
Documented assessment of suicide and homicide risk where relevant, a safety plan when needed, and your clinical judgment stated clearly.
Provider identification
The rendering provider's name and credentials, a signature (electronic signatures are generally acceptable), and the date of service.
Support for the code billed
Interventions described in enough detail, the complexity of the case, and your clinical decision-making, so the documentation supports the specific code.
Common psychotherapy CPT codes and what to document
| Code | Service | Time | Document |
|---|---|---|---|
| 90832 | Individual psychotherapy | 16 to 37 minutes | Time, interventions, response, progress |
| 90834 | Individual psychotherapy | 38 to 52 minutes | Start and stop times, specific interventions, response to treatment, progress toward goals |
| 90837 | Individual psychotherapy | 53 minutes or more | Precise times, the clinical need for the longer session, interventions used throughout |
| 90846 | Family psychotherapy without the patient | About 50 minutes | Who attended, why the patient was absent, how the session serves the patient's treatment plan |
| 90847 | Family psychotherapy with the patient | About 50 minutes | Everyone present, the patient's participation, family interventions, link to treatment goals |
General guidance only. Check the current CPT definitions and your payers' policies.
How My Clinical Writer helps
- Templates that prompt for required elements. Build your diagnosis, functional impairment, medical necessity, time, interventions, progress and risk sections into the template once, and every draft is laid out the same way.
- Drafts from what actually happened. Record a summary or type key points after the session, and the AI writes them up in the template's structure.
- Progress against goals. Upload earlier notes or the treatment plan so the draft can describe change against the goals you set.
- Your review comes last. Check the note, fill any gaps, and confirm the time and interventions before you copy it to your EHR or billing system.
For note formats, see SOAP notes for therapy and therapy progress notes.
The AI drafts. You decide.
My Clinical Writer writes a first draft from what you record, type or upload. You review it, edit anything that does not match your clinical judgment, and only then sign or export it. The assessment, the diagnosis and the plan are always yours, and you remain responsible for the final record.
Patient data is protected as described on our security and HIPAA page: 256-bit encryption in transit and at rest, role-based access, audit trails, and a Business Associate Agreement that every account accepts at registration.
Questions, answered.
What is medical necessity, and how do I document it?
Medical necessity means showing why therapy is clinically required. Link the diagnosis to functional impairment (how symptoms affect work, relationships and daily activities), connect your interventions to those impairments, and show that the level of care is appropriate. You can add these prompts to your templates so every draft includes them for you to complete.
How precise does time documentation need to be?
Psychotherapy CPT codes are time-based, so record the actual start and stop times or total time. For example, 90834 covers 38 to 52 minutes, and a 53-minute or longer session is billed as 90837. Make sure the documented time supports the code you bill, and check your payer rules.
Does My Clinical Writer choose the CPT code for me?
No. Code selection is your decision. The draft documents the session details you provide, including time and interventions, so the note can support the code you choose.
Do requirements differ between insurers?
The core elements are similar, but specific requirements vary by payer, and Medicare and Medicaid have their own rules. Check the documentation policy of each payer and build what they require into your templates.
Does this guarantee my claims will be paid or pass an audit?
No tool can guarantee that. My Clinical Writer helps you produce complete, consistent notes, but you are responsible for their accuracy and for what you bill.
How does it fit with my EHR or billing system?
Copy the finished note into your EHR or billing system, or save it as a Word document.
Try it on your next note.
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