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Coding and medical record documentation reminders for behavioral health claims
Act
immediately
Effective date
Jul 1, 2023
Identified
Jun 19, 2026
Summary
BCBSRI issued updated coding and documentation requirements for behavioral health claims, emphasizing proper E/M coding based on 2021 AMA changes, time-based psychotherapy documentation, and specific requirements for billing E/M with psychotherapy on the same day to combat rising healthcare fraud.
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What to do
immediately · 4 steps
01Billing team and providers must ensure E/M codes (99201-99215) are selected based on medical decision making or time, not history/exam level.
02For psychotherapy codes (90834, 90833), document actual time spent and therapeutic maneuvers.
03When billing E/M with add-on psychotherapy (90833), ensure services are separately identifiable with minimum 16 minutes psychotherapy time documented.
04Update documentation templates to include therapeutic maneuvers, treatment goals, and progress notes for all psychotherapy services.
Codes mentioned
992019920299203992049920599211992129921399214992159083490833
Original notice
Coding and medical record documentation reminders for behavioral health claims
bcbsri.com · Always check the source before changing claims.
Related changes
See all Blue Cross Blue Shield of Rhode Island changes →Tips and documentation standards for interactive complexity and psychotherapy with E/M servicesHighEffective Jul 1, 2026 · Behavioral HealthSplit billingHighEffective Jan 1, 2020 · Provider UpdatePayment Policy UpdatesHighEffective Jul 1, 2024 · Physician / FacilityPayment policy updatesHighEffective Jul 1, 2024 · Physician / FacilityBrowse every Blue Cross Blue Shield of Rhode Island change in the policy list