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Progress note completeness checklist

Last reviewed October 12, 2026 · 4 min read

A complete progress note shows who was seen, when, for how long, what was done and how it relates to the plan. The time you document must support the CPT code you bill. Use this checklist on a sample of your own notes, on screen or printed and ticked by hand.

9083216 to 37 minutes
9083438 to 52 minutes
9083753 minutes or more
TimeStart and stop times or total time

Treatment plan guide

CPT psychotherapy codes and time

Code	Psychotherapy with patient	Time range in the Medicare billing article
90832	30 minutes	16 to 37 minutes
90834	45 minutes	38 to 52 minutes
90837	60 minutes	53 minutes or more

The ranges come from Medicare billing and coding article A57520 (First Coast Service Options), which asks providers to "choose the code closest to the actual time" and states that "start and stop times or total times must be documented" for these codes. Unverified Commercial plans generally follow CPT time rules but can publish their own policies; check yours. Add-on codes with an E/M service (90833, 90836, 90838) and crisis codes are not covered here.

Form only. This checklist looks at completeness and consistency. It does not tell you which code to bill or what to write, and it does not replace your payer's documentation policy.

Identification

Client name or identifier on every page.
Date of service.
Place of service and, for telehealth, the modality used.

Time and code

Start and stop times, or total psychotherapy time, documented.
Documented time falls within the range of the CPT code billed.
No overlap with another client's session at the same time.
Date, code and units on the note match the claim.

Content

Current symptoms or presenting problem addressed in the session.
Interventions described specifically, not "supportive therapy provided".
Client participation and response recorded.
Change or lack of change in symptoms or behavior noted.
Plan for the next session or next steps.

Plan link

A treatment plan was in force on the date of service.
The note refers to at least one goal or objective of that plan.
Diagnosis codes on the claim match the plan and the record.

Signature and corrections

Legible handwritten or electronic signature with credentials.
Date of signature recorded.
Late entries and corrections show their own date and author; nothing is backdated.
Psychotherapy notes, if you keep them, are stored separately from the record.

PsyClinicAI · psyclinicai.com/us/guides/progress-note-checklist.html · Last reviewed October 12, 2026. General information, not legal or billing advice.

Frequently asked questions

Is 53 minutes the minimum for 90837?

In the Medicare billing article A57520, 90837 covers 53 minutes or more of psychotherapy. Check your payer's policy, as commercial plans can differ.

Do I need start and stop times, or is total time enough?

The Medicare article accepts either start and stop times or total time for 90832, 90834 and 90837. Some payers ask for start and stop times; follow your contract.

Does the time include writing the note?

Psychotherapy codes are based on time spent in psychotherapy with the patient and/or family member. Note-writing time after the session is generally not counted. Check the CPT descriptor and your payer's policy.

Is anything stored when I use this page?

No. The page has no form. Nothing is sent, stored or tracked, and the page sets no cookies.

Sources

CMS Medicare Coverage Database: Billing and Coding article A57520, Psychiatric Diagnostic Evaluation and Psychotherapy Services (First Coast Service Options), read on October 12, 2026: cms.gov
CMS Medicare Coverage Database: LCD L33252 (progress note content): cms.gov
CMS: Medicare Program Integrity Manual, Chapter 3, sections 3.3.2.4 and 3.3.2.5 (signatures, amendments and delayed entries) (PDF): cms.gov
45 CFR 164.501, definition of psychotherapy notes: law.cornell.edu
Unverified CPT code descriptors are published by the AMA under license and were not reproduced or checked here; commercial payer time policies were not checked individually.

First published October 12, 2026. Last reviewed October 12, 2026. General information, not legal, billing or clinical advice. Check your payer contract, state rules and the cited sources before relying on it. Written by the PsyClinicAI team. Corrections: support@psyclinicai.com.