Current Procedural Terminology (CPT) codes and general documentation guidance

Current Procedural Terminology (CPT) codes are used by mental health providers to identify and bill for services like therapy sessions, psychiatric evaluations, and medication management. These standardized codes make it easier for providers, insurers, and patients to communicate and ensure accurate billing. Using the right CPT codes is how providers get paid for their work.

 

Adding CPT codes to confirm sessions

When confirming a session in our system, you’ll select a CPT code and ICD-10 diagnosis code(s). This information allows us to file the claim with insurance, bill your client, and process your payment.

You’ll choose codes from a dropdown menu, and the most common codes will appear at the top for convenience. You can also scroll through the full list.

If you don’t see a code on the list, it may not be part of our contract. Reach out to us with any questions around missing codes.

 

General documentation guidance

Progress notes are important for keeping track of a patient’s care, diagnosis, and progress. They’re a key part of the patient’s medical record and should include details from each session, like the start and stop times, treatment methods used, symptoms observed, progress toward goals, and the plan for next steps. These notes also serve as your proof of the services you provided for insurance billing, ensuring accuracy, accountability, and continuity of care.

As a general rule, the following documentation components are required for ALL CPT codes billed:

Patient name and date of birth

Every document for billing must include the patient’s full name and date of birth on each page. We recommend adding this information in the header or footer. Headway templates automatically include these details, but if you use a different EHR, make sure your printed documentation does too. If you need help adding this information, reach out to your EHR vendor for support.

 

Location of service

When documenting services, note whether the session was provided virtually or in-office. For telehealth sessions, include telehealth consent and reference the use of HIPAA-compliant software. Additionally, document both the patient’s location and the provider’s location during the session to comply with state licensing laws. Be sure to specify whether the session was facilitated via audio/video or audio-only (audio-only is currently allowed only for Medicare and Medicaid clients).

 

Date of service

Include the full date of service (month, day, and year) on all documentation, matching the session confirmation date.

 

Total duration of session

Record the exact start and stop time and/or the total session duration in minutes. For psychotherapy codes, this refers to the time spent face-to-face with the patient.

For evaluation and management (E/M) codes, this article provides additional information on what can be included in total session duration.

 

Chief complaint / History of presenting illness

The chief complaint captures the patient’s primary reason for the session, guiding clinical focus and ensuring the documentation demonstrates medical necessity, supports continuity of care, and meets compliance with legal and ethical standards. It provides a clear context for interventions and tracks progress over time.

 

 

Person-centered details

Each progress note should be unique to the individual and session. While some details from previous sessions may carry over, the majority of content should reflect the unique clinical picture of the session including the patient's experiences, goals and concerns. Person-centered documentation ensures individualized treatment, supports accurate billing, enhances patient engagement, and maintains compliance.

 

 

Therapeutic interventions used

Documenting therapeutic interventions in progress notes is crucial for tracking patient progress and adjusting treatment as needed. It demonstrates medical necessity and supports reimbursement by showing that services are appropriate, aligned with the treatment plan, and based on evidence-based practices (EBPs) that are reimbursable by payers. Proper documentation ensures effective, ethical, and accountable care.

Please note: Complementary approaches, such as art therapy or mindfulness, are typically only covered when used alongside an evidence-based practice (EBP) as part of the treatment plan.

For guidance on evidence-based practices, visit:

• APA PsycTherapy Evidence-Based Approaches
• Evidence-Based Practices Resource Center | SAMHSA
• Research-Supported Psychological Treatments
  
  

 

Mental Status Exam (MSE)

The mental status exam (MSE) is a critical component of progress notes, offering an evaluation of a patient’s cognitive, emotional, and behavioral functioning. It supports medical necessity documentation and ensures compliance with reimbursement requirements. By providing a snapshot of the patient’s mental state during a session, the MSE aids in diagnosis, treatment planning, and clinical decision-making. At Headway, psychotherapy notes must include at least three MSE categories, while intake/assessment and E/M codes require at least five.

Some suggested categories for an MSE include appearance, behavior, speech, mood and affect, thought process, thought content, perception, cognition, insight, judgment, and risk assessment. Below is an example of how this information can be effectively captured and documented using Headway’s progress note template:

 

 

Risk assessment

Documenting a risk assessment in progress notes is essential for patient safety. It helps identify potential risks, guides clinical decision-making and ensures the appropriate level of care. Proper documentation fulfills legal and ethical responsibilities, protecting both the patient and provider. Additionally, risk assessments are often required for reimbursement, helping to justify the treatment provided. Depending on your clinical approach, you may use a formal risk assessment tool or address risk more generally.

For more information on risk assessments, take our course on Headway Academy: Risk Assessment and Safety Planning. 

 

 

Diagnostic statement

Providers must include the current ICD-10 diagnosis, along with the diagnostic criteria and specific features the patient is experiencing that substantiate the billed diagnosis. Utilizing diagnostic screening tools is encouraged to aid in determining and documenting the diagnosis accurately.

A diagnostic statement should be clear, detailed, and directly aligned with the diagnosis code(s) billed. Additionally, documentation must describe the progression of the patient’s symptoms, specifying whether they are improving, worsening, or remaining stable.

Headway offers providers access to clinical assessments which can assist with documentation of diagnostic statements and symptoms.

For further guidance on accessing clinical assessments through the provider portal, please visit our article: Clinical assessments on Headway.

 

 

Clinical summary and assessment

The clinical assessment focuses on evaluating and describing the patient’s current status, including symptom progression, therapeutic response, and overall well-being, forming a critical link in the "golden thread" of documentation. Its primary purpose is to guide treatment planning and decision-making while ensuring patient safety, effective interventions, and improved outcomes.

This section provides a detailed account of the patient’s observable progress, stagnation, or regression, emphasizing specific symptoms and their response to treatment. By tying these elements to the treatment plan and ongoing interventions, clinicians create a cohesive and comprehensive summary of the patient’s needs and the therapy's effectiveness.

 

 

Medical necessity justification 

The medical necessity statement substantiates why therapy is essential for the patient’s health and functional improvement. It provides a clinical rationale to justify treatment to insurance providers, ensuring compliance with billing requirements and standards of care. This section links the patient’s symptoms and impairments directly to the need for continued therapeutic intervention, reflecting the therapist’s clinical impression based on subjective and objective information. It explicitly outlines why the treatment plan should continue, be modified, or conclude, ensuring that the therapy aligns with the patient’s clinical needs.

To learn more about medical necessity, visit our article: Medical necessity. 

 

 

Progress toward treatment plan goals

The clinical assessment evaluates the patient’s status, symptom progression, and therapeutic response, forming a vital part of the "golden thread" of documentation. It guides treatment planning and ensures effective, safe interventions by linking observed progress or challenges to the treatment plan.

Including treatment plan goals in progress notes is essential to demonstrate medical necessity, linking session activities to objectives and ensuring compliance with payer requirements for accurate billing.

For guidance and examples, visit our Resource Center: How to write a mental health treatment plan (with examples).

 

 

Plan

Documenting a plan in progress notes is vital for ensuring continuity of care and establishing a clear roadmap for future treatment. It guides the clinician’s approach in subsequent sessions and ensures that interventions remain focused on the patient’s evolving needs and progress. A well-documented plan also facilitates alignment among all team members, if applicable, and supports accurate billing and documentation for payers.

For guidance and examples, visit our Resource Center: How to write progress notes (with examples).

 

 

Provider name, credentials, signature, and date signed 

All documentation must include the provider’s name, credentials (as listed with payer credentialing), signature, and the date signed. For e-signatures, the documentation should include a statement such as “electronically signed by” or “signed by.”

While some of this information may overlap with what Headway collects automatically in your calendar, insurance companies require these details to be explicitly included in your notes. For more detailed information on progress notes and code-specific documentation requirements, additional resources are available at the bottom of this page.

 

 

Special attention: Notes saved elsewhere

Headway’s clinical templates provide structure and support, helping reduce note-taking time while ensuring all key elements required by insurers are addressed. Therapists using these templates have an 80% higher pass rate on internal and external audits.

If you choose to use a separate EHR for your practice, ensure that all information on the session confirmation page matches the documentation in your progress notes.

The following details must be identical between your claim (session confirmation) and your progress notes:

• Patient name and date of birth (DOB)
  • This is typically included in the header or footer of progress notes. If needed, contact your EHR vendor for assistance in adding these details.
• Provider name and credentials
• Session date and time (start/stop)
  • If you update start and stop times in your EHR, be sure to update them in the session confirmation as well.
• Session duration
• Patient location
• CPT code(s)
• Diagnosis(es)

By ensuring consistency across these elements, you can avoid discrepancies that may delay reimbursement or impact compliance with payer requirements. 

 

Additional resources

General guidance

• Behavioral health compliance: A Headway Guide
• 10 Insurer requirements commonly missing from notes
• Keeping progress notes on Headway
• How to write progress notes (with examples)
  • How to write DAP notes (with examples)
  • How to write SOAP notes (with examples)
  • How to write BIRP notes (with examples)
• Documentation/Billing and Coding (Provider Policies)
  
  

Code-specific guidance 

• The 10 most common CPT codes (and how to use them)
• How to use CPT code 90791
• How to use CPT code 90792
• How to use CPT code 90832
• How to use CPT code 90834
• How to use CPT code 90837
• How to use CPT code 90846
• How to use CPT code 90847
• Evaluation and Management (E/M) codes with add-ons
• Psychiatrist and nurse practitioner resource hub
• How to use CPT codes 90839 and 90840: Psychotherapy for crisis
• How to use CPT code 90785 for interactive complexity