This template documents a medication management visit and the psychotherapy delivered in the same session, built so the clinical record and the insurance claim agree with each other.
Head of Growth and Operations, JotPsych
A prescriber who also does therapy in the same visit is doing two billable things at once, and payers want both justified on their own terms. This template keeps psychopharmacologic management, adjusting and monitoring medication, and psychotherapy, the therapeutic conversation itself, in separate, clearly labeled sections instead of one blended narrative. It fits outpatient psychiatry, integrated behavioral health, and any psychiatric nurse practitioner or psychiatrist visit that combines medication management with cognitive behavioral therapy (CBT), supportive therapy, motivational interviewing, or another evidence-based approach.
What the template captures
History and mental status
The history of present illness (HPI) carries the session's clinical narrative: mood, anxiety, sleep, or psychotic symptoms, functional status, medication adherence and side effects, and what changed since the last visit. The mental status exam (MSE) section holds the objective findings, appearance, behavior, speech, mood and affect, thought process, cognition, and insight and judgment, documented specifically enough that another clinician picking up the chart mid-treatment can follow the reasoning.
Assessment and plan
One narrative section ties the visit together: current symptom status, whether the medication is working, the diagnosis, planned changes to medication or labs, safety issues, and the goals carried into psychotherapy. Writing it for the next clinician who reads the chart, not just as a formality, is what makes it useful six months later.
The add-on psychotherapy section
This is where the template earns the add-on in its name. It documents the type of therapy, the specific techniques used, what the session covered, how the patient engaged, and the minutes spent on psychotherapy within the visit, because the add-on codes bill by time. A note might read: psychotherapy comprised 25 minutes of the 45-minute visit, focused on CBT for anxiety; the patient identified a distorted thought pattern and practiced a thought record.
Billed by the minute
The three psychotherapy add-on codes are defined by how long the psychotherapy portion runs, on top of the medication management service. Documenting the actual time spent is what lets the visit support the code billed.
Minutes of psychotherapy required for each add-on code under CPT. Source: American Medical Association CPT code definitions. A note documenting fewer minutes than the code requires gets the add-on downcoded or denied outright, so the therapy time and the medication time have to be written down separately.
Built for the billing rule, not just the note
The add-on codes exist because payers will not pay for psychotherapy and a medication visit as though they were two separate encounters. CPT codes 90833, 90836, and 90838 must be billed alongside a qualifying E/M code; office visit codes 99202 to 99205 for a new patient or 99212 to 99215 for an established one, never alone. JotPsych's billing engine checks this automatically: a claim carrying a psychotherapy add-on with no E/M code on it gets flagged before it reaches the payer, and if the E/M code is missing modifier 25, the marker that tells a payer the E/M service was separately identifiable from the therapy delivered the same day, JotPsych warns the provider before submission.
In JotPsych
The E/M and add-on psychotherapy template is one of 25+ pre-built templates in JotPsych's public library, built specifically for the dual-focus visit. Selecting it before the encounter sets the structure, and the note's sections fill in from the recording as the visit happens. Editing a shared template never changes JotPsych's original: the first edit automatically creates the clinician's own copy, so a version customized for a specific therapy modality does not touch the copy the rest of the practice uses.
“The amount of data it adds to notes is crazy. Whatever code I use, the note will be more than sufficient to support it. And I need to do next to nothing.”Psychiatrist, medical director, multi-location practice
One session, two billable services, one record that supports both.
See JotPsych's templatesSource: JotPsych. CPT code definitions, American Medical Association. Testimonial: JotPsych clinician feedback.