AI-drafted notes take 3 checks before you sign
Once you sign, the draft's codes are yours. Before you sign, check the session time, the code, and each intervention the draft lists.
Co-founder, JotPsych
When the AI draft of your 2:00 session's note suggests 90837 and your 3:00 is in the waiting room, run three checks before you sign.
Session: 2:00 to 2:50 PM, 50 minutes.
Cognitive behavioral therapy for panic attacks.
Suggested code: 90837
Session: 2:00 to 2:50 PM, 50 minutes.
Cognitive behavioral therapy for panic attacks.
Code: 90837 90834
The AI draft suggested 90837 for 50 minutes of therapy. The clinician changed the code to 90834 before signing, so the claim's code matches the note's minutes.
- Read the session time. Start there, since the code depends on the minutes. Compare the start and stop times in the draft with your calendar. Fix a wrong time before you do anything else.
- Match the code to the minutes. Noridian, a Medicare contractor, lists CPT's time ranges: 90832 for 16 to 37 minutes of psychotherapy, 90834 for 38 to 52, and 90837 for 53 or more. Change the code when your minutes fall in another range, even when the draft's code pays more.
- Check each intervention the draft lists. Read each line against what happened in your session. Delete any intervention you didn't use, like a breathing exercise you never taught. Add any you used that the draft missed. Then sign.
If you bill Medicare, its reviewers can ask for the session times in your note. The Program Integrity Manual bars them from requesting your psychotherapy notes, but session start and stop times don't count as psychotherapy notes. So a reviewer can see a wrong session time in a note you signed.
Notes that document or analyze what was said in a session
Kept apart from the rest of the record
Session start and stop times
The type and frequency of treatment
Diagnosis, symptoms, treatment plan, and progress
Psychotherapy notes stay protected only when they're kept apart from the rest of the record. Before you sign a therapy note, check each item a reviewer can request against the session it records.
Expect a Medicare reviewer to lower the code and the payment when your note's minutes support a lower code than the one billed. The manual's coding rules have the reviewer adjust the claim, not deny it.
Signing a note affirms that "the note adequately documents the care provided," the manual says. The same rule applies when AI transcribes the note.
Set the session time, and JotPsych's final review shows that time with the billing codes before you sign.
See JotPsych- Noridian Healthcare Solutions, Medicare contractor, Mental Health billing guidance, Jurisdiction E Part B.
- Centers for Medicare & Medicaid Services, Medicare Program Integrity Manual, chapter 3, section 3.3.2.4, Signature Requirements, and section 3.3.2.6, Psychotherapy Notes, both effective January 17, 2025, and section 3.6.2.4, Coding Determinations, effective August 27, 2020.