Clarifying Billing Compliance: What Actually Matters vs. What Doesn't

This article reflects my clinical approach to documentation—not legal advice. Adapt these frameworks to your scope, setting, and clinical judgment.

There's a lot of confusion in recent discussions about scheduling, documentation, and billing compliance. Some of it stems from legitimate caution. Some of it comes from incomplete information getting passed around as absolute rules.

Let me clarify what auditors actually look for, because some claims being made don't align with CPT guidance or CMS rules.

What IS a Compliance Violation

Billing for time you didn't actually spend
If you spent 10 minutes on therapy and bill 90833 (requires 16-37 min), that's fraud.

Mathematical impossibility
If your schedule shows patients every 20 minutes all day with no gaps, and you're billing 99214 + 90836 (38-52 minutes) for each one, the math doesn't work. That's a legitimate red flag.

Documentation that doesn't support the code
If you document "supportive statements made" and bill for 25 minutes of psychotherapy, your documentation doesn't support the time billed.

Systematic patterns of billing therapy when no therapy occurred
Adding 90833 to every visit because "that's how you make money" without actually performing therapeutic intervention.

What IS NOT a Compliance Violation

Scheduled time not matching actual time spent
Your calendar is not your billing documentation. If you schedule 20 minutes and the visit actually takes 27 minutes, you document and bill 27 minutes. That's accurate billing, not fraud.

Visits running longer than scheduled
A patient scheduled for 20 minutes has an SI spike, now it's 30 minutes. You document 30, bill for 30. Not a violation.

Calendar blocks that don't perfectly align with billing codes
Auditors review your clinical notes and overall patterns, not whether your Google Calendar matches your superbill.

Billing is based on actual documented time, not scheduled time. This is fundamental to CPT guidance.

Can You Bill E/M + Psychotherapy in a 20-Minute Appointment?

Yes, when you understand how E/M coding actually works and how integrated psychiatric care is delivered.

The Critical Misunderstanding

E/M levels are NOT based on how long you spend talking about medications. They're based on MDM (Medical Decision Making): the complexity of problems addressed, data reviewed, and risk involved.

A "brief med check" doesn't mean you spent four minutes on medications and now you need to justify the other 16. It means the E/M component was appropriate for the complexity of the case, regardless of how much time you spent discussing the prescription itself.

Examples of appropriate MDM requiring minimal medication discussion time:

Stable bipolar patient, high baseline severity
Reviewing therapy notes, assessing for early relapse signs, updating safety plan = 99214 or 99215 based on MDM, even if medication discussion takes 3 minutes

Panic disorder with new onset chest pain
Reviewing cardiology workup, risk assessment for cardiac vs. psychiatric symptoms = high MDM, even if you don't change medications at all

Depressive episode with passive SI
Performing structured safety assessment, coordinating with therapist, reviewing outpatient records = moderate to high risk, regardless of med changes

The length of "medication discussion" is not the determining factor for E/M level. MDM complexity is.

E/M and Psychotherapy Are Interwoven, Not Sequential Blocks

This is where the confusion happens. People conceptualize the visit as:

"First I do 4 minutes of med management, THEN I do 16 minutes of therapy."

That's not how integrated psychiatric care works.

In reality:

• You're assessing symptoms (E/M) while also processing the patient's emotional response to those symptoms (psychotherapy)

• You're discussing medication adherence (E/M) while exploring barriers and resistance (psychotherapy)

• You're evaluating risk (E/M) while building safety planning skills (psychotherapy)

• You're reviewing treatment response (E/M) while addressing cognitive distortions about progress (psychotherapy)

The clinical work happens simultaneously. The documentation reflects both components because both are occurring, often in the same conversational exchange.

A realistic 20-25 minute visit with 99213/99214 + 90833:

• Brief symptom review: "How's your anxiety this week? Any panic attacks?" (2 min)

• Medication adherence/side effects: "Lexapro still working? Any issues?" (1 min)

• Safety assessment: "Any thoughts of harming yourself or others?" (1 min)

• Clinical decision-making: Assessing whether current plan is working, considering adjustments (happens throughout, documented after)

Then 16-20 minutes of focused therapeutic intervention:

• CBT: Identifying cognitive distortions around specific trigger

• Motivational interviewing: Exploring ambivalence about treatment adherence

• Supportive therapy: Processing recent stressor with coping strategies

• Psychoeducation: Teaching specific skill relevant to presenting problem

Total: 20-25 minutes of integrated psychiatric care.

Is this every appointment? No. Comprehensive evaluations, complex medication changes, crisis management require longer slots.

But routine follow-ups with appropriate complexity and focused therapy? Absolutely can happen in 20-25 minutes when you're actually performing both services.

What Auditors Actually Look For

Audits focus on documentation, internal consistency, and billing patterns over time, not isolated scheduling discrepancies.

Does your documentation support the time you billed?
If you document 25 minutes of psychotherapy with specific modalities and content, you can bill 90833 regardless of what your calendar said, as long as total visit time and documentation support it.

Do your patterns make mathematical sense?
Full-day patterns that are impossible (8 hours of services billed in a 4-hour work block) are red flags. Individual visits running over scheduled time are not.

Is psychotherapy actually being performed with documented modalities and content?
Not just "patient educated" or "supportive statements made."

Are you billing for services you didn't provide?
This is fraud regardless of scheduling.

What Legitimate Compliance Requires

✓ Document actual time spent in psychotherapy (not scheduled time, actual time)
✓ Document modalities used and specific content addressed
✓ Ensure your overall patterns make mathematical sense
✓ Bill what you actually performed
✓ Make sure MDM documentation supports the E/M level you're billing

Bottom Line

Yes, impossible scheduling patterns are red flags. Yes, systematic upcoding triggers audits. Yes, you must actually perform the services you bill.

But "your calendar must match your billing" is not how compliance works.

Billing is based on actual documented time and clinical complexity, and visits don't always fit neat calendar blocks.

If you're going to make practice decisions based on compliance concerns, base them on actual CPT guidance and CMS rules, not on fear about scenarios that conflate real violations with normal clinical variation.