The insurance company is reviewing one or more claims submitted on your behalf. Sending complete, accurate records is the fastest way to get this resolved. This guide covers everything your documentation needs to include.
What to include on every page of every record
Each page of every document you submit must contain:
Patient's full name
Date of birth and/or member ID
Date of service
This applies to every page — not just the first one.
What every session note must include
Each visit note must stand on its own. Do not rely on a previous session's note to explain what happened on a different date of service. Every note should independently reflect:
The patient's presenting complaint or concern for that visit
Your clinical assessment
The treatment rendered during that session
The patient's response and outcomes
What your psychotherapy notes need to show
Generic statements like "therapy provided" or "patient is improving" are not sufficient. The insurance company needs to see what actually happened in the session.
Your notes should describe:
The symptoms or concerns the patient brought to the session
The specific therapeutic interventions you used (e.g., CBT, trauma-focused interventions, psychoeducation, mindfulness, behavioral activation, supportive therapy)
Your clinical observations during the session
How the patient responded to your interventions
Progress toward treatment goals
Any updates to the treatment plan
A good gut check: someone who wasn't in the room should be able to read your note and understand what happened, what you did, and why.
Intake and initial evaluation documentation
If the records request includes an initial evaluation or intake, that note should contain:
Chief complaint
Relevant medical and psychiatric history
Mental status examination
Diagnosis and clinical impressions
Treatment plan with therapeutic goals and proposed interventions
Family and social history when clinically relevant
Your treatment plan must align with the diagnoses and services documented.
Time documentation (for timed CPT codes)
If the claim includes a timed CPT code (like 90837), your note must clearly document the actual face-to-face time spent with the patient.
Start and stop times are strongly recommended
Total session duration must be stated
Only direct therapy time counts
Do not include:
Scheduling or administrative tasks
Documentation completed after the session
Wait time
Example: "Psychotherapy session conducted from 2:00 PM – 2:53 PM for a total of 53 minutes."
Telehealth sessions
If any sessions were conducted via telehealth, each note must also include:
Your location at the time of service
The patient's location at the time of service
The platform or modality used (e.g., video, audio-video)
A clear statement that the session was conducted via telehealth
Modifiers
Claims must include accurate modifiers that reflect the nature of the service — including telehealth, supervision, or any other payer-required billing circumstance. Your documentation must support whatever modifier was billed. Missing, incorrect, or unsupported modifiers can result in denial or audit findings.
CPT code and billing accuracy
The CPT code billed must accurately reflect:
The type of service performed
The complexity of the session
The duration of service (for timed codes)
The units billed
Your documentation needs to fully support the code, modifiers, and units on the claim. If the notes don't clearly back up what was billed, the insurance company may deny or recoup the claim.
Medical necessity
Your records need to clearly establish why treatment was clinically required — not just that it was provided. This should be evident throughout your documentation, not only in the intake.
Each note should demonstrate:
Why treatment was needed at that point in time
The severity of the patient's symptoms
How symptoms are impacting the patient's day-to-day functioning
That there is an ongoing clinical need for services
The clinical rationale for the interventions used
Provider and rendering provider requirements
The provider documented in your notes must match the rendering provider listed on the submitted claim. Rendering providers must be properly licensed and must bill under their own credentials.
If a supervised clinician or trainee delivered the service:
The note must specify who performed each portion of the service
The note must be signed by both the rendering provider and the supervising licensed provider
Signatures
Every note must include:
Provider signature
Professional credentials
Signature date
Electronic signatures are acceptable. Your signature confirms that you rendered or supervised the documented services and that the documentation is complete and accurate.
Coordination of care
If applicable, include any records related to:
Referrals made or received
Consultation reports
Communication or coordination with other providers
Care planning discussions
Follow-up recommendations
Checklist before you send
☐ Patient name, DOB/member ID, and date of service on every page
☐ Each note stands independently and is specific to that session's date of service
☐ Presenting problem, assessment, treatment rendered, and patient response are documented
☐ Therapeutic interventions are clearly described — not generic
☐ Time is documented with start/stop times and supports the CPT code billed
☐ Telehealth location, modality, and confirmation of telehealth delivery are included (if applicable)
☐ Modifiers on the claim are accurate and supported by documentation
☐ CPT codes, units, and modifiers match the documentation
☐ Medical necessity is clearly established throughout the records
☐ Provider signature, credentials, and signature date are on every note
☐ Rendering provider in notes matches the rendering provider on the claim
☐ Supervised/trainee services include signatures from both providers (if applicable)
☐ Intake documentation includes treatment plan, diagnosis, and goals (if applicable)
☐ Coordination of care records are included (if applicable)