Documentation Specificity for Behavioral Health
Key Takeaways
Behavioral health documentation must meet state Medicaid requirements, demonstrate medical necessity and active treatment, include face-to-face time when applicable, and support accurate billing and coding.
Providers should document session dates, duration, service types, interventions, client status, risk factors, and plans for future treatment while balancing privacy considerations.
Evaluation and Management behavioral health documentation should include the chief complaint, history of present illness, mental status exam, assessment, plan of care, and time when required.
Health Behavior Assessment and Intervention services require documentation of the reason for the assessment, tools used, provider interpretation, treatment goals, progress toward outcomes, and time for time-based services.
Accurate ICD-10-CM code assignment depends on clear documentation of diagnoses, behavioral risk factors, or treatment noncompliance, and a provider query is necessary when the reason for the encounter is unclear.
Coding and reporting Behavioral Health services can be challenging in the face of the evolving movement to integrate physical and behavioral healthcare. Behavioral Health is now the responsibility of every provider and not just the psychiatric community. Despite great strides in removing the social stigmata associated with mental health care and addiction treatment, providers are reluctant to document the details of their encounters in the interest of patient privacy. Diagnosis assignment of mental health disorders can also present a challenge to providers who do not have a mental health focus and experience with the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, Text Revision (DSM V TR) criteria.
Authoritative resources for documentation and coding of Behavioral Health Services are scarce. The Centers for Medicare and Medicaid Services (CMS) published a Guide to Behavioral Health Medical Record Keeping for Medicaid. BehavioralHealthFS121115.pdf This guide provides the following seven requirements for documentation of Behavioral Health Services in general:
“Meet that State’s Medicaid program rules;
To the extent required under State law, reflect medical necessity and justify the treatment and clinical rationale (remember, each State adopts its own medical necessity definition);
To the extent required under State law, reflect active treatment;
Be complete, concise, and accurate, including the face-to-face time spent with the patient (for example, the time spent to complete a psychosocial assessment, a treatment plan, or a discharge plan);
Be legible, signed, and dated;
Be maintained and available for review; and
Be coded correctly for billing purposes.”
The American Psychological Association (APA) published a guideline on record keeping for Psychologists (Record keeping guidelines), and Guideline 2 indicates the following:
“A psychologist makes choices about the level of detail in which the case is documented. Psychologists balance client care with legal and ethical requirements and risks. Information written in vague or broad terms may not be sufficient if more documentation is needed (e.g., for continuity of care, mounting an adequate defense against criminal, malpractice, or state licensing board complaints). However, some clients may express a desire for the psychologist to keep a minimal record in order to provide maximum protection and privacy. Although there may be advantages to keeping minimal records, for example, in light of risk management concerns or concerns about unintended disclosure, there are, alternatively, legitimate arguments for keeping a highly detailed record. Those may include such factors as improved opportunities for the treatment provider to identify trends or patterns in the therapeutic interaction, enhanced capacity to reconstruct the details of treatment for litigation purposes, and more effective opportunities to use supervision and consultation.”
The APA guideline then goes on to identify the following types of record keeping and what should be included as follows:
“For each substantive contact with a client:
Date of service and duration of session
Types of services (e.g., consultation, assessment, treatment, training);
Nature of professional intervention or contact (e.g., treatment modalities, referral, letters, e-mail, phone contacts);
Formal or informal assessment of client status.”
“The record may also include other specific information, depending upon the circumstances:
Client responses or reactions to professional interventions;
Current risk factors in relation to dangerousness to self or others;
Other treatment modalities employed, such as medication or biofeedback treatment;
Emergency interventions (e.g., specially scheduled sessions, hospitalizations);
Plans for future interventions;
Information describing the qualitative aspects of the professional-client interaction;
Prognosis;
Assessment or summary data (e.g., psychological testing, structured interviews, behavioral ratings, client behavior logs);
Consultations with or referrals to other professionals;
Case-related telephone, mail, and e-mail contacts;
Relevant cultural and sociopolitical factors.”
Please note that there is nothing in this guideline that specifically cites rendering a diagnosis or the reason for the encounter, which needs to be documented. Documentation of a diagnostic statement and chief complaint may need to be the focus of provider education since it is not evident in the professional guidance provided by the APA.
The American Psychiatric Association training presentation (APA-Webinar-Slides-2025-Billing-and-Documentation-Update.pdf) from 2025 included a documentation table on slide 29 indicating the following items should be captured for an Evaluation and Management Encounter:
The reason for the Visit/Chief Complaint addresses clinical and billing reasons for the encounter. Additional bullet points included:
History of Present illness,
Review of Systems,
Past Psychiatric History,
Family Psychiatric History,
Past Medical History,
Mental Status Exam,
Assessment and Plan
Time as appropriate.
The American Psychiatric Association also cited the following documentation guidelines for psychotherapy add-on services:
Should be separate from and follow the documentation related to the E/M visit. To Include:
Time spent providing psychotherapy (requirements by payer vary; some payers/states may require start/stop times)
Type of therapeutic intervention (i.e., insight-oriented, supportive, behavior modification)
Target symptoms
Progress toward goals
In 2020, the AMA rolled out an overhaul of the Behavioral Health Assessment and Intervention (HBAI) CPT codes and the guidelines used to describe them. Services covered in this section of codes are intended to identify and address associated psychological, behavioral, cognitive, emotional, and interpersonal factors that are integral to assessing and managing specified disease-related problems.
Behavioral Health services are divided into assessments and interventions. The behavioral health assessment is performed via focused interviews, standardized assessment tools, and observation. These assessments provide a picture of the person’s emotional, psychological, and social well-being and identify behavioral health conditions that can impact a patient’s ability to function in the face of disease and/or injury. The assessment looks at the patient's coping mechanisms, outlook, motivation, and the potential to adhere to a plan of treatment.
When a Behavioral Health Questionnaire is employed, the test results and the interpretation should be documented. Behavior Health Questionnaires commonly used include the following:
PHQ-9 (Patient Health Questionnaire) – Screens for depression
GAD-7 (Generalized Anxiety Disorder Scale) – Assesses symptoms of anxiety
THQ (Trauma History Questionnaire) – Assess experiences with potentially traumatic events.
Functional Assessments can extend beyond the patient interview to include parents, teachers, or caregivers. The Functional Behavior Assessment identifies the purpose or function associated with behaviors interfering with reaching treatment goals. Documentation must indicate what the assessment entailed and the provider’s interpretation with a treatment plan to address the problem.
Risk Assessments are used to identify urgent safety concerns, such as suicidal or homicidal ideation. These are also used to identify substance use and related risks. Risk assessment tools commonly employed include:
Patients with Intellectual Development Disabilities (IDD) will often require modifications in treatment plans and interventions to accommodate the patient’s level of intellectual functioning. The assessment for and identification of a need for specific modifications must be documented. Evidence-based Practices for IDD | NC Complex Mental Health and Intellectual Developmental Disabilities Resources
Reporting Health Behavior assessments and reassessments is done with CPT Code 96156. The notes must identify the reason for the assessment, the assessments performed, and the interpretation of each assessment. Time is not a factor in reporting this code.
Behavioral Health interventions can be provided to an individual, group, or in family sessions with or without the patient present. The goals of this type of intervention include promotion of functional improvement, minimization or elimination of psychological or psychosocial barriers to recovery, and improving coping mechanisms with regard to medical conditions. Reporting these interventions is a time-based activity, and time must be documented, as well as who was included in the session. Documentation should, at a minimum, identify the topics discussed and any pertinent achievements towards the goal of removing barriers to good health.
CPT codes 96156 – 96171 are time-based services and, as such, TIME must be documented. CPT codes 96158, 96164, 96167, and 96170 are not reported for less than 16 minutes of service. Per CPT Assistant August 2020, “Evaluation and management (E/M) services codes (including counseling risk factor reduction and behavior change intervention [99401-99412]) should not be reported on the same day as the HBAI codes by the same health care professional.”
When an E/M service is performed by a different physician or qualified healthcare provider (QHP) from the provider reporting HBAI, then services represented by codes 96156-96171 may be reported on the same date of service as the E/M services. This includes counseling risk factor reduction and behavior change intervention [99401-99404, 9940699409, 99411, 99412]), as long as the HBAI service is reported by a physician or QHP.
Additional coding guidance from the AMA also indicates health behavior intervention services (96156-96171) should not be reported in conjunction with psychiatric services (90785-90899) on the same date of service. In this scenario, coders are directed to report the predominant service performed. Psychological testing performed in addition to the health assessment or re-assessment should be additionally reported, based on the type of testing performed.
These patients may or may not have a mental health diagnosis. If the patient has an established mental health diagnosis, this should be listed in support of these services. In the absence of a mental health diagnosis, the Z72 family of ICD-10-CM codes for high-risk behavior can be a resource to show the medical necessity for the encounter. Signs and symptoms involving appearance and behavior found in the R46 family of codes are also an option. Noncompliance with medical treatment is found under the Z91 family of ICD-10-CM codes, which may be a fit. This category of diagnosis codes illustrates a variety of noncompliance behaviors that can impact a plan of treatment for patients.
Ambiguity in the patient record can result in errors in diagnosis assignment. A query to the provider should be initiated when the clinical record does not clearly identify the reason for the encounter and/or a diagnosis.
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