What is necessary when reporting add-on psychotherapy codes?

When reporting add-on psychotherapy codes, it is essential that the documentation for each service performed—including add-on services—must stand alone. This means that the documentation should provide enough detail to clearly support the medical necessity of the service itself without relying on the documentation of other services. The integrity of the documentation is critical to ensure that it meets compliance standards and substantiates the coder's billing practices. Each code represents a specific service that should be clearly delineated in the patient's records, which helps protect against audits and ensures proper reimbursement.

In the context of the other options, including the time documented for E/M services can be relevant, but it does not negate the need for the documentation for the add-on service to be self-contained. Similarly, while it is often ideal for both services to be performed by the same provider for clarity and convenience, it is not an absolute requirement for proper coding. Lastly, a verbal report alone does not suffice. Proper documentation must be in writing to support coding decisions and billing, ensuring that all aspects of the service provided are adequately recorded.