10 Insurer requirements commonly missing from notes

Insurance companies occasionally review documentation, like treatment plans and progress notes, to verify the services they pay for. Keeping compliant notes—whether on Headway or with another service—is the best way to ensure your clients’ claims get processed as smoothly as possible.

Based on our conversations with insurers, here are 10 of the items most commonly missing from charting documentation, including examples of what it takes to meet the requirements for each.

Note: Headway documentation templates can help walk you through several of the items below. Learn more about our templates here.

 

  1. A statement of progress toward specific goals and objectives with a reference to the treatment plan

    ❌ Tom is making progress toward his goals.

    ✅ Tom made progress toward his treatment plan goal of managing social anxiety, as shown by two successful public outings where he practiced his new mindfulness and breathing techniques.

    ✅ Scott's treatment plan goal is to learn three new coping skills for anxiety that work in his social life/environments. Progress today: regressing. Needs new interventions.

  2. Location of service, including whether it was in-person or telehealth, and an indication that telehealth sessions were performed using a HIPAA-compliant audio/visual platform
    • Note: Headway’s clinical templates will automatically place the necessary statement(s) in your final note once you select your session’s location. 

    ❌ [The note includes no mention of the location of the service.]

    ❌ [The session details say in-person, but the notes suggest the meeting was virtual.]

    ✅ I had a telehealth session with Jane where I was in my private office and Jane was calling in by herself from her bedroom. We used HIPAA-compliant audio/visual software [Zoom, doxy.me, SimplePractice, etc.].

  3. A complete mental status exam, with at least 3 categories* present (e.g., affect, appearance, behavior, mood, orientation, speech, thought content, thought process)
    • Note: *Initial Assessment or Intake codes like 90791 and 90792 should include a full mental status exam. Headway’s intake note templates include the full exam.

    ❌ Aurora's mental status appeared stable.

    ✅ Aurora's affect was sad and her speech was flattened, but her thought process showed concrete reasoning and her memory was sound.

  4. A description of symptoms that support the diagnosis

    ❌ Oscar has Generalized Anxiety Disorder.

    ✅ Oscar's diagnosis of Generalized Anxiety Disorder is supported by the following symptoms: Oscar reports feeling irritable, and constantly finding feelings of worry difficult to control...

  5. Person-centered details like client quotes and specific behavior

    ❌ Sarah came into the session. She was sad.

    ✅ Sarah said, "I feel stressed and sad when I wake up." She pointed out that her outfit was 3 days old and her hair was disheveled.

  6. A recommendation for follow-up care and the associated level of service (for psychiatric diagnostic evaluations using billing code 90791)

    ❌ [The documentation provides no details on future sessions or what the level of care should be going forward.]

    ✅ Having diagnosed Antoine with Major Depressive Disorder, I have recommended he continue to see me every 2 weeks to assess progress on goals and interventions. We plan to discuss a possible referral for medication intervention.

  7. A problem statement that includes a diagnosis

    ❌ [The documentation jumps straight into details of the session without any context on the initial problem or official diagnosis.]

    ✅ Alyssa originally sought out therapy following frequent panic attacks - at work and often in public. After diagnosing her Social Anxiety Disorder, we have been considering some interventions to help her manage public settings.

  8. A risk assessment, and if risk is identified, a corresponding safety plan
    • Note: Headway's clinical templates can walk you through a risk assessment.

    ❌ [The client brought up a risk, but there is no risk assessment.]

    ❌ [There is a risk assessment, but no corresponding safety plan.]

    ✅ Tom has acknowledged a temptation to engage in self-harm. As a result, we have worked together on a safety plan to avoid further harmful action, with the following steps:...

    ✅ Patient denies all areas of risk. No contrary clinical indications present.

  9. A provider signature and credentials
    • Note: Headway’s clinical templates include an attestation checkbox that serves as an electronic signature. Providers may also add “/s/” next to their name to signify an electronic signature. 

    ❌ [Note has handwritten or digital signature, and no comment on the provider's credentials.]

    ✅ Note signed by provider /s/ Jane Doe, Licensed Marriage and Family Therapist

  10. A CPT code that matches the session time, provided that particular code is billed by time

    ❌ [Session start and stop times are 35 minutes apart, but provider bills CPT code 90837 (only for sessions 53+ minutes).]

    ✅ [Session length was 63 minutes, and provider billed CPT code 90837.]

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