A practical guide for utilizing psychotherapy notes in your EHR

8 minute read

The prevalence of mental health conditions and the need for adequate treatment has long been on the rise in the United States. Early in the COVID-19 pandemic, many areas experienced a spike in demand for behavioral health services, and since then, overall demand seems to have returned to pre-pandemic levels.[1] Still, behavioral health providers need to be prepared for continued and increasing demand. Statistics related to mental health, in general, are compelling. Approximately half of all Americans will experience a mental health condition at some point in their lives.[2] Additionally, 46.3 million people aged 12 or older (16.5%) experienced a past year substance use disorder (SUD), and 19.4 million adults have co-occurring mental illness and SUD.[3] The global societal impact of poor mental health is expected to increase to $6 trillion by 2030.[4] Anecdotal feedback within our own system suggests that depression, anxiety, increased substance use, and post-traumatic stress disorder have been the most common reasons for people seeking treatment since 2020.

Often, individuals seeking treatment for any number of conditions receive psychotherapy. From a clinical perspective, psychotherapy is a broad term referring to a type of behavioral health therapy, often called “talk therapy.” The services are facilitated by individuals whose academics and training evolved from social and behavioral sciences. These professionals can include a psychiatrist, psychologist, or other licensed mental health provider. These skilled clinicians are trained to rely on a variety of treatment modalities that can be utilized to help the patient achieve their desired goals. Behavioral health providers can sometimes be heard referencing the use of a “clinical toolbox” comprised of various evidence-based methods. A few of the more common modalities involve cognitive behavioral therapy, interpersonal therapy, and solution-focused brief therapy. Benefits of seeking therapy are numerous, ranging from acquiring problem-solving skills, self-care techniques, and gaining confidence. Psychotherapy tends to fall into four common categories: individual, group, couples, and family.[5] Psychotherapy is described by service codes 90832–90838 in the Current Procedural Terminology manual.[6] An encounter for psychotherapy may be supplied as a stand-alone visit or on the same day as an evaluation and management service (in which the 25 modifier rules apply).

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