Clinical and Documentation Essentials
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Psychotherapy billing and documentation for PMHNPs
E/M + 90833
When you provide at least 16 minutes of psychotherapy in a visit where you are also managing medications, you can bill an E/M code (for example 99213 or 99214) plus 90833. The key is to show psychotherapy work and a treatment plan within the note.
Core requirements
  • Medically necessary E/M visit (for example 99213 or 99214).
  • At least 16 minutes of psychotherapy delivered.
  • Psychotherapy content clearly distinct from med-management.
  • Psychotherapy time explicitly documented in the note.
Treatment plan within the note
PMHNPs do not need a separate “therapist-style” plan. The treatment plan must be built into your documentation and should clearly show:
  • Identified problem or problems.
  • Treatment goals or therapeutic focus for the session.
  • Interventions you provided during the session.
  • Expected outcome or plan going forward.

Examples that satisfy this include: identifying emotional triggers and improving communication, working on maladaptive coping patterns, supporting emotion regulation and trust issues, and outlining continued psychotherapeutic work in the plan.

Suggested language

Psychotherapy duration: 21 minutes (supportive therapy and CBT interventions). Session focused on recent interpersonal conflict leading to emotional triggering and defensive responses. Explored trauma-related attachment patterns; used cognitive restructuring and communication coaching. Patient engaged well; will continue to work on trust, boundaries, and emotion regulation in follow-up sessions.

90833 add-on 16–37 minutes Treatment plan inside note
Coding and compliance basics
Core codes
Use codes that accurately reflect the complexity of the visit and the services provided. When in doubt, document your reasoning clearly.
Frequently used codes
  • 90792 – Psychiatric diagnostic evaluation.
  • 99213–99215 – E/M med-management visits.
  • 90833 – Psychotherapy add-on (16–37 minutes).
  • 96127 – Brief emotional/behavioral screening (PHQ-9, GAD-7, ADHD tools).
E/M level guidance
  • 99213 – Stable chronic illness, low complexity, limited medication changes.
  • 99214 – Multiple chronic conditions, active medication adjustments, moderate complexity.
  • 99215 – High complexity, significant safety risk, crisis or intensive management.

Focus on number and complexity of problems, risk of medications, and management decisions. Time can also drive coding if your documentation supports it.

Audit awareness
  • Align time, content, and codes.
  • Show medication risks, benefits, and rationale for changes.
  • Document functional impact (work, school, relationships, safety).
Document complexity Function and risk Screeners with 96127
Telehealth requirements
Video visits
Telehealth visits must meet the same clinical standards as in-person care, with a few extra documentation pieces to show where everyone is and that consent was given.
Always document
  • Patient location (state) during the visit.
  • Provider location when providing care.
  • That the visit occurred via audio and video.
  • That patient/guardian provided consent for telehealth.
Psychotherapy via telehealth

Psychotherapy add-on codes are allowed for telehealth if your documentation shows psychotherapy time and content just as it would for in-person care.

Consent in every note Patient and provider location
Clinical visit workflows
Flow
Use a consistent structure for each visit so documentation is easier and care is predictable for patients.
Medication management visit
  • Review symptoms, functioning, and chief concerns.
  • Review response to current medications and side effects.
  • Make dose changes or new prescriptions as needed.
  • Address safety and risk (SI, HI, self-harm, ability to care for self).
  • Set follow-up timing and any labs or monitoring.
Combined therapy and med-management
First, complete the E/M piece (symptoms, medications, risk, plan). Then shift into psychotherapy content for at least 16 minutes. In the note, clearly separate med-management language from psychotherapy focus and interventions.
Predictable visit flow Clear separation of services
Provider onboarding and training
New to NPM
This section outlines what new providers should become comfortable with in their first weeks.
Core onboarding topics
  • How to document a full psychiatric evaluation (90792).
  • How to update availability and templates in Tebra.
  • How follow-up scheduling works for med-management and therapy.
  • Spravato workflow overview if applicable to your role.
  • Overview of accepted insurance plans and authorization processes.
Support contacts

For onboarding questions, reach out to practice leadership or admin by email.

First 30 days Documentation standards
Tebra EHR quick guides
System tips
Short reminders for where to document key elements in Tebra so billing and clinical information stay aligned.
Common tasks
  • Submit prescriptions and review refills.
  • Attach and score screening tools such as PHQ-9 or GAD-7.
  • Document psychotherapy minutes and content.
  • Send referrals and review clinical documents.
Minimal clicks Consistent documentation
Spravato program essentials
TRD care
Spravato visits have additional safety, monitoring, and documentation requirements that must be followed for REMS, payers, and internal standards.
Core expectations
  • REMS requirements followed and documented.
  • Vital signs taken at required time points.
  • Continuous observation in the treatment space.
  • Pre-dose, intra-visit, and post-dose assessments documented.
Coverage and patient cost

Check payer coverage and patient responsibility before induction. Use internal scripts, checklists, and coordination with support staff so patients fully understand cost and options.

Safety first REMS-compliant documentation
Accepted insurance plans
Coverage
This section is a quick reference and should match internal billing and front desk documentation.
In-network plans (subject to change)
  • BCBS Nebraska plans.
  • UHC commercial plans.
  • Cigna commercial plans.
  • Medica Health Plans (commercial).
  • Oscar Health Insurance.
  • UMR commercial plans.

Molina and Medicare are not being accepted at this time until further notice. Always verify plan details and network status before promising coverage.

Verify each visit Coordinate with billing
Emergency and risk protocols
Safety
When safety concerns arise, focus on clear assessment, immediate steps to keep the patient safe, and thorough documentation of your reasoning.
Key elements
  • Assess suicidal ideation, plan, means, and intent.
  • Assess ability to care for self and protect others.
  • Determine whether outpatient care is appropriate or if higher level of care is needed.
  • Document safety plan and instructions (911, 988, ER, contacts).
If acute risk is present
If the patient is at acute risk of harm and cannot reliably maintain safety, direct them to the nearest emergency department or call emergency services. Document who you spoke with, what you advised, and why.
Clear rationale Document conversations