CommercialDocumentationMedium impact
Coding and medical record documentation reminders for behavioral health claims
Blue Cross Blue Shield of Rhode Island·RI · Psychiatry·Behavioral Health
Effective date
Jul 1, 2023
We identified it
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.
Action Required
Immediately: Billing team and providers must ensure E/M codes (99201-99215) are selected based on medical decision making or time, not history/exam level. For psychotherapy codes (90834, 90833), document actual time spent and therapeutic maneuvers. When billing E/M with add-on psychotherapy (90833), ensure services are separately identifiable with minimum 16 minutes psychotherapy time documented. Update documentation templates to include therapeutic maneuvers, treatment goals, and progress notes for all psychotherapy services.