Let’s talk about one of the most frequently used—and frequently misunderstood—billing combinations in behavioral health: Evaluation and Management (E/M) services billed with add-on psychotherapy codes.

On the surface, this combo makes perfect sense. The prescriber is managing medications and also engaging the client in therapy. But from a billing and documentation standpoint? It’s a minefield.

And trust me—payers are watching.

I won’t call out names, but I’ve personally seen behavioral health organizations forced to repay hundreds of thousands (yes, hundreds of thousands) of dollars after payers took a closer look at how this was being documented and billed. It wasn’t fraud. It wasn’t intentional. It was simply a case of doing it the way it had always been done—and not realizing the requirements were being misunderstood or misapplied.

So what’s the problem?

Most of the time, the documentation doesn’t distinguish psychotherapy from the E/M. Instead, providers document one continuous note, often with good clinical content, but no clear separation. And when that happens, payers will deny the add-on or go back and recoup funds across dozens, even hundreds, of encounters.

Here’s what’s missing most often:

• No clear time statement for the psychotherapy component
• No separate documentation of the therapeutic modality, focus, or response
• No indication that the provider spent time beyond what was needed for medication management
• No connection to the treatment plan

Even worse, some organizations rely on macros that copy forward the same “therapy” note across multiple visits—or use vague language like “supportive therapy provided” without actually describing what took place.

Bottom line: Providing support or having an emotional conversation doesn’t necessarily meet the threshold for billable psychotherapy.

And here’s the real kicker: When prescribers do provide real psychotherapy—but fail to document it correctly—they’re not just risking denials. They’re missing the chance to show payers the true value of what’s being done.

So What Can You Do?

1. Train your prescribers. Don’t assume your docs or NPs “know how to document.” Most were never taught how to split E/M and therapy in a compliant way.
2. Audit regularly. Don’t wait for a payer to request records. Review your own documentation and be brutally honest—would it stand up to scrutiny?
3. Use templates that support compliance—but don’t autopilot. A good template should prompt the right elements but still require real, individualized documentation.

Final Thought:

The psychotherapy add-on isn’t the problem. It’s a valid, billable service when done and documented correctly. But without the right safeguards in place, it can quietly become a risk you didn’t see coming.

If you’re not sure your documentation holds up—or you’ve already had a close call—let this be your sign to take a second look.

Because what you don’t know can cost you.