You just finished the visit.
You spent part of it managing medications. You also worked with the patient on avoidance, ambivalence, grief, a relationship pattern, catastrophic thinking, distress tolerance, or something else that was clearly therapeutic.
And now you are staring at the psychotherapy section thinking: what exactly was that? Was it CBT? Supportive psychotherapy? MI? Something DBT-informed? What do I actually write for the intervention?
That is the problem this post is meant to solve.
The goal is not to give you canned language that turns an ordinary conversation into psychotherapy. The psychotherapy has to have actually happened, which is what Thursday's post was about. The goal here is to help you recognize and accurately describe therapeutic work you already performed.
Companion resource. The Psychotherapy Documentation Phrasing Bank collects the modality, intervention, focus, response and time language discussed below, in Word and PDF. It comes with Forum and Full membership, or $7 on its own.
There is no single national psychotherapy note that every payer requires. Documentation expectations differ by Medicare contractor and by plan.
That is a reason to stop hunting for the universal template, not a reason to document four different ways. Nobody is going to keep a Medicare style, an Aetna style and a commercial style and pick one based on the card in the chart. You would get it wrong under time pressure, and the effort would buy you nothing.
So the approach I use, and the one this post teaches: write to the stricter standard and use it for everyone. If someone reviewing the chart wants to know what psychotherapy was provided, the answer should be obvious without them hunting for it.
This is about how I document the service, not how I decide which code applies. Coding still follows the CPT criteria.
When I look back at psychotherapy I provided during a medication-management visit, I want to be able to answer five things.
1. What was the therapeutic approach? CBT, motivational interviewing, supportive psychotherapy, insight-oriented work, DBT-informed work, ACT-informed work, behavioral activation, exposure-based work.
2. What did I actually do? This is the intervention. Cognitive restructuring. Reflecting discrepancy. Behavioral activation. Affect labeling. Distress-tolerance practice. Values clarification. Exposure planning.
3. What were we working on? The specific clinical target: catastrophic thinking, alcohol-use ambivalence, avoidance, grief, interpersonal conflict, emotional dysregulation, low motivation.
4. How did the patient respond? What did they recognize, practice, generate, tolerate, commit to, or understand?
5. How much psychotherapy time did I actually provide?
That gives you a far more useful structure than "supportive therapy provided."
These five are not a verbatim national requirement. They are what I document because together they make it hard for a reviewer to wonder what kind of psychotherapy this was, what I did, what I was treating, whether the patient engaged, and whether there was enough time for the code.
This is the distinction that matters most.
If you document:
Provided CBT.
you have named the therapeutic approach, but you have not shown what you actually did.
If you document:
Used cognitive restructuring to identify and challenge catastrophic predictions about having another panic attack.
you have described the intervention.
Put the two together:
Provided CBT targeting catastrophic interpretations of physical sensations. Used cognitive restructuring and Socratic questioning to examine feared predictions. Patient generated two alternative explanations and demonstrated increased ability to recognize the thought-anxiety cycle.
Now the documentation tells a clear story: what kind of psychotherapy this was, what you did inside it, what you were treating, and how the patient engaged.
This is probably the more common problem, and it is the one the phrasing bank exists for.
You do not need to sit across from the patient thinking I am currently performing motivational interviewing. Most clinicians do not practice that way. You may recognize the modality afterward, when you look back at what actually happened.
A few translations.
You helped the patient examine an automatic thought, test its accuracy, or develop an alternative interpretation. That is consistent with CBT, using techniques such as cognitive restructuring or Socratic questioning.
You explored ambivalence, reflected discrepancy, elicited the patient's reasons for change, or strengthened change talk. That is motivational interviewing.
You helped the patient process an emotional experience, identify affect, strengthen coping, work through a stressor, or improve adaptation without using a more structured change protocol. That may be supportive psychotherapy.
You connected what is happening now to a pattern that has happened before, or surfaced why a reaction is occurring. That is insight-oriented work.
You taught and practiced distress tolerance, emotion regulation, mindfulness, or interpersonal effectiveness skills. That may be DBT-informed psychotherapy.
You worked on acceptance, values, cognitive defusion, experiential avoidance, or values-consistent action. That may be ACT-informed work.
You worked directly with avoidance through a planned behavioral experiment or exposure exercise. That may be exposure-based psychotherapy or CBT.
The name helps characterize the work. The intervention shows what actually happened. You want both.
Some things look therapeutic on the page and do not establish a psychotherapy service by themselves.
Psychoeducation by itself does not establish psychotherapy. Explaining a medication's mechanism, reviewing expected side effects, teaching general sleep hygiene, or explaining a diagnosis are ordinarily part of the E/M service. Psychoeducation can certainly be incorporated into psychotherapy, but education alone does not turn the encounter into 90833.
Safety planning is not a psychotherapy modality. Risk assessment, warning-sign review, crisis planning, and emergency thresholds are psychiatric care and do not become psychotherapy merely because they are lengthy or emotionally significant. Therapeutic work can occur alongside safety planning, but that psychotherapy has to be identifiable on its own.
Empathy, validation, reassurance and reflective listening can all be genuine therapeutic techniques, but their presence alone does not establish a separately reportable service. Nearly every good psychiatric visit contains them.
That is why the documentation should not just name a technique. It should show what therapeutic work the technique was being used to accomplish.
Two of these were treated as stand-alone categories in the earlier version of this phrasing bank, with ready-made language under each. If you downloaded it, stop using the psychoeducation and safety sections as stand-alone psychotherapy categories. The updated bank below also tightens several of the remaining examples so the language describes actual therapeutic work rather than simply therapeutic communication.
For psychotherapy performed with an E/M service:
Real psychiatric visits interweave. Assessment, medication work, education and therapeutic work move back and forth. You are not going to produce this:
9:00 to 9:08 medication management
9:08 to 9:28 psychotherapy
9:28 to 9:35 medication management
and you should not try. Medicare contractor guidance on combined visits recognizes that the psychotherapy time may be noncontinuous.
What does have to hold: the psychotherapy time is time spent doing psychotherapy, it excludes the E/M work, and the two services have to be separately identifiable. You are apportioning the visit, not segregating it.
And when the add-on is on the claim, the E/M level is selected by medical decision making rather than by time.
PSYCHOTHERAPY ([time] minutes): [Modality] targeting [clinical focus]. [Specific intervention performed]. Patient [response, engagement, insight, skill use].
Three real ones:
PSYCHOTHERAPY (20 minutes): Provided CBT targeting catastrophic interpretations of physical sensations associated with panic. Used cognitive restructuring and Socratic questioning to examine feared predictions. Patient identified two recurring catastrophic thoughts and generated alternative interpretations with minimal prompting.
PSYCHOTHERAPY (22 minutes): Used motivational interviewing to address ambivalence about reducing alcohol use. Reflected discrepancy between stated health goals and current drinking, and elicited patient-generated reasons for change. Patient identified one personally meaningful reason to cut back and chose a specific change to try this week.
PSYCHOTHERAPY (18 minutes): Provided supportive psychotherapy focused on grief and difficulty adjusting after a recent loss. Used affect labeling, reflection and exploration of coping responses to help the patient process the loss and identify adaptive supports. Patient identified previously unrecognized guilt and named two supports she plans to use this week.
These phrases are not necessarily wrong. The problem is that each one leaves out something important about the psychotherapy that actually occurred.
"Provided CBT."
Good, you have identified the modality. Now show what you actually did inside CBT.
Provided CBT targeting catastrophic predictions about returning to work. Used cognitive restructuring to examine the prediction that returning would lead to failure or embarrassment. Patient identified all-or-nothing thinking and generated two alternative interpretations.
The modality tells me what kind of psychotherapy this was. The intervention tells me what you actually did.
"Discussed coping skills."
This one is too vague because I cannot tell what the therapeutic intervention actually was.
If what happened was skill practice, say that:
Provided DBT-informed psychotherapy targeting acute anxiety and distress tolerance. Practiced paced breathing and paired muscle relaxation from the TIPP skills in session. Patient completed the exercise and identified when she could use it before an upcoming work presentation.
"Discussed coping skills" tells me there was a conversation. "Practiced paced breathing and paired muscle relaxation" tells me what therapeutic work occurred.
"Patient motivated for change."
This describes the patient, not what you did therapeutically.
If you used motivational interviewing, document the intervention first, then the response:
Used motivational interviewing to explore ambivalence about cannabis reduction and reflected discrepancy between current use and the patient's goal of improving morning functioning. Patient generated two reasons for reducing use and selected an initial reduction goal.
Now I can see both sides of the therapeutic exchange: what the clinician did, and how the patient responded.
The fix is not replacing the modality with the intervention, and it is not adding more clinical-sounding adjectives. It is making sure the note answers the whole question: what approach did you use, what did you actually do within it, what were you working on, and how did the patient respond?
The download is organized Modality, Intervention, Focus, Patient Response, Time.
Do not pick five phrases that sound good and assemble a section. Start from the encounter, then use the bank to find accurate language for it. That is the difference between a documentation aid and a template that writes a service you did not provide.
You do not have to label the modality and technique while you are talking to the patient.
When an encounter contains psychotherapy, the Scribe suggests likely modalities drawn from what the visit actually contains, with "no psychotherapy this visit" always available, and you confirm. If the note already documents a named intervention you performed, it drafts from that work instead of asking. Then it builds the section on the same five elements.
The boundary is the one running through all of this: it suggests, you confirm. It should not manufacture therapy that did not happen, and if the encounter only contains medication education and reassurance, there is nothing for it to find.
Open the Psychotherapy Documentation Phrasing Bank in the Template Library
Both formats are on that one card:
📄 Word (.docx) Editable and searchable, easy to keep beside your documentation workflow.
📘 PDF (.pdf) Quick reference for saving or printing.
Both are organized Modality, Intervention, Focus, Patient Response, Time, with complete worked examples.
It comes with Forum and Full membership, or $7 on its own.
Psychotherapy Documentation is live in the Practice Lab under Billing and Coding. You work through cases and decide: did psychotherapy happen, what kind of therapeutic work occurred, how would you document it, and does the documentation support what was billed.
And for the coding side rather than the wording, CPT Coding Logic for PMHNPs covers what can and cannot sit on the same claim.
Your turn. Which of the five is hardest for you to write? For me it is the patient-response line, because the honest answer is sometimes "she listened and said it made sense," which is not much of a response to document.