Why 60 Minutes Isn’t Enough: Surprisingly 90837 Fails Audits More Than You Would Expect

If you are billing 90837 the 60-minute individual psychotherapy code with any regularity, you are likely already on payers’ radar. Not because you’re doing anything wrong. But because this is one of the highest-scrutinized codes in outpatient behavioral health, and the documentation patterns we see showing up in audits across the country are remarkably consistent.

The problem isn’t that providers aren’t delivering 60 minutes of care and yes and by that we mean a minimum of 53 minutes. Many actually are. The problem is that the record doesn’t prove it and more importantly, the record doesn’t prove why the 60-minute code was medically necessary for that patient, on that date, given where they are in treatment.

That's the line payers are drawing; and most providers don't know it exists.

What 90837 Actually Requires and What’s Routinely Missing

The 90837 is billed for psychotherapy sessions of 53 minutes or more with a patient. That time threshold is the floor, not the standard. Payers are not just asking “How long was the session?”—they’re asking, “Why did this patient need 60 minutes instead of 45?”

The required elements that consistently fail in reviews:

• Documented session start and end time. Not just the code billed. Auditors want to see time reflected in the note, not assumed from the CPT code.
• The specific intervention used. “Therapy provided” is not documentation. CBT, DBT, motivational interviewing, trauma-focused techniques name what you did and how the client responded. Worth noting: Templates that are built to include every possible intervention without specifically what was provided and how that factored into care will not qualify for documented intervention.
• Measurable client response. The note should reflect observable, functional change or documented reason why progress is limited or delayed.
• A direct tie back to the treatment plan. If an auditor cannot draw a straight line from the note to an active treatment plan goal, the claim is at risk.

The Duration Question: How Long Has This Patient Been in Therapy?

This is where I see organizations get blindsided. Payers are not only reviewing individual notes they are reviewing the pattern across the episode of care. And when a patient has been receiving 90837 consistently for 18, 24, or 36 months without a clear clinical rationale for ongoing intensity, that longitudinal picture becomes a liability. As a non-clinical based auditor, we simply note it as feedback when we see this type of pattern. It’s not judgement, it’s just a “raising the red flag” proactively because we’ve seen the payers feedback over the years.

The question auditors are asking when they pull long-term therapy records:

• Why does this patient still require 60-minute sessions?
• What has changed clinically to justify the same level of service over time?
• Is the treatment plan still active, current, and reflective of where the patient actually is?
• Has the frequency or intensity been clinically reassessed or stepped down as the patient has stabilized?
• Are progress notes showing evolution, or are they essentially copies of each other month over month?

Long-term therapy is not inherently problematic. Many patients genuinely require extended treatment. But the record has to tell that story. If the notes from month six look nearly identical to the notes from month twenty, payers interpret that as either lack of progress or lack of clinical necessity neither of which protects your claim.

The Treatment Plan Connection: Your First and Last Line of Defense

I cannot overstate how often this is the deciding factor in an audit. Treatment plans that were written at intake and never meaningfully updated are a serious compliance exposure especially when the services being billed have changed in focus, intensity, or clinical rationale.

A treatment plan that supports 90837 billing must:

• Identify specific, measurable goals that the 60-minute sessions are working toward non-general wellness language.
• Reflect the current clinical picture, not where the patient was at admission. Outdated diagnoses, stale goals, and old baselines signal to auditors that treatment is on autopilot.
• Be updated at required intervals and those updates should reflect genuine clinical reassessment of where the patient currently is in treatment, not a date stamp on a recycled document.
• Be signed by all required parties according to your state licensing rules and payer contract requirements. Don’t forget this one!

Every 90837 note should function as a chapter in the larger story the treatment plan is telling. If a payer pulls 10 notes and cannot trace them back to an active, current, defensible treatment plan the claim stack pulled and potentially the universe of claims is at risk. All of it.

Medical Necessity: The Vaguely Defined Pendulum That Swings Both Ways

Medical necessity for 90837 is not a static determination made at intake and never revisited. It is a living, ongoing clinical argument for providers that must be re-established through documentation in progress notes, at every review of the treatment plan, and basically across the full episode of care.

The pendulum swings toward medical necessity when the records show:

• Active psychiatric symptoms or functional impairment that require therapeutic intervention
• Clinical complexity that genuinely requires extended session time to address safely
• Documented progress toward treatment goals, or a clinical rationale for why progress is slow or non-linear
• A treatment plan that is specific, current, and responsive to where the patient is now
• Evidence that the clinician is actively driving the work, not simply providing ongoing support

The pendulum swings away from medical necessity when the record shows:

• Flat or generic notes that read the same month after month
• A patient who appears clinically stable with no documented rationale for continued intensity
• An outdated treatment plan that no longer reflects the patient’s current clinical status or goals
• Long-term utilization of 90837 without any documented reassessment of frequency or level of care
• Sessions that read more like check-ins than active, goal-directed therapy

What to Do Right Now

If you are billing 90837 across your organization, the time to self-audit is before the payer does it for you. Start with these steps:

• Pull a sample of long-term 90837 cases specifically those in treatment 12 months or more. Read the notes longitudinally. Ask whether the record tells a clinical story or a billing pattern.
• Audit your treatment plan update cadence. Are plans being updated at required intervals? Are the goals still clinically relevant? Are the signatures current?
• Check for documented session times. If your progress notes do not reflect start and end time, correct that now not after you receive a records request.
• Review your note templates. If your providers are documenting from a checkbox or a copy-paste structure that doesn’t contain a good narrative to document their clinical justification, that template is a liability in an audit.
• Build a policy around peer driven step-down reviews. Patients who have been stable for extended periods should have a documented clinical discussion about whether 90837 remains the appropriate level of service or whether 90834 or a reduced frequency is clinically indicated. This is better through peers and is essentially not included in a typical billing and compliance audit review.

Final Thought

The 90837 is not a dangerous code to bill. It’s a necessary one. There are patients who genuinely need that time and that level of clinical intensity and the providers delivering that care deserve to be paid for it.

But the record has to carry the argument. Every session. Every update. Every treatment plan review. Because when a payer pulls your charts, they are not asking whether you care about your patients. They are asking whether your documentation proves the services were medically necessary, clinically appropriate, and delivered as billed.

If you’re unsure whether your 90837 documentation would hold up in a review, that uncertainty is your answer. Don’t wait for the audit letter to find out.

Reach out if you want a focused clinical documentation review on your psychotherapy service lines. We’ve seen what payers are looking for and we know exactly where the gaps are hiding.