Headway, as well as insurance companies, will periodically conduct reviews of claims and clinician records. This is done to ensure accuracy and compliance with regulatory standards, as well as address possible instances of fraud, waste, or abuse. Learn more here.
Unlike a traditional billing company, Headway acts as your practice partner and shares the responsibility of maintaining compliance. To help meet compliance standards, a dedicated and specialized team at Headway will review charting documentation to look out for things like commonly missing items or repeated mistakes.
We will only provide feedback on notes that don’t initially meet requirements.
Responding to feedback
When we flag notes with missing requirements for you to review in your portal, you must respond by the given deadline, which is typically 3 business days from when you receive the feedback. In order to respond, click Review feedback in your provider portal.
Purpose of an addendum
An addendum is a dated, signed supplement to an existing clinical note that clarifies or adds information discovered after the original documentation was completed.
It allows a provider to maintain an accurate and complete medical record without altering the original entry.
When an addendum is appropriate
Addenda should be used only when:
- New or clarifying information became available after the note was signed (e.g., lab results, collateral input, client recall, etc.)
- You realized an omission in documentation that needs correction or elaboration
- You need to document a late entry (e.g., forgot to record vital info during the encounter, but recall it accurately)
Do not use an addendum to rewrite or replace the original note, or to change the billed code retroactively.
Required elements of a compliant addendum
Each addendum must include:
- Header identifying it as an addendum: For example, “Addendum (Section: Diagnosis/Assessment)” or “Addendum: Plan Update”
- Date and time the addendum is written (not the original service date)
- Author’s signature, credentials and date signed
- Clear purpose statement: Explain what you’re clarifying or adding, and why
- No modification of original content: Reference the original note, but never overwrite or delete it
- Objective language only: Avoid speculative or retrospective justifications (e.g., “I must have…” or “I probably did…”)
If you use Headway’s free text addendum instead of uploading your own, the first 3 bullets will be covered for you.
What not to include:
- Rewriting or re-signing the original note
- Questions, comments, or feedback for the Headway team (reach out to us directly for that)
Example of a compliant addendum
Addendum (Section: Plan/Medication Management)
Date: November 6, 2025
The diagnosis entered at session confirmation did not match the diagnosis documented in the clinical note. The correct diagnosis is Major Depressive Disorder, recurrent, moderate (F33.1).
No changes are made to the treatment plan or interventions as documented.
Signature: [Provider Name, PMHNP-BC]
Quick reference table
| ✅ DO | 🚫 DON'T |
| Add missing facts you can confirm (e.g., medication name, lab, date) | Add details you don’t recall clearly |
| Use factual, time-stamped language | Edit or delete the original entry |
| Write “Addendum” in the title or first line | Label it as a “correction” or “update” without date/signature |
| Use to clarify documentation or close a loop | Use to challenge feedback or justify coding |
Key takeaways
- Addenda maintain record integrity — do not rewrite records
- Always date, sign, and clearly label your addenda
- Only add what you know to be accurate
- Never use addenda to retroactively “qualify” for a billing code
- Remember: all addenda are part of the permanent medical record and subject to payer review or audit
Responding to feedback that cannot be addressed with an addendum
There are some circumstances where it might not be possible to action feedback in an addendum. In those cases, you can select Acknowledge without addendum and choose from the reasons below:
- The documentation I have provided is accurate and complete
- I’m unable to make updates to the flagged items (e.g. I don’t recall specifics of the session)
- Other (please specify)
Additional guidance and resources
If you would like additional guidance and resources on the feedback you received, you can search the table below for the specific feedback topics and text given to you in Sigmund:
| Feedback topic | Specific feedback text | Additional guidance and resources |
| Add on psychotherapy | Duration and/or start-stop time of the add-on psychotherapy is either not documented separately from the total session time, not appropriate for the selected add-on CPT code, and/or inconsistent throughout the documentation. When billing add-on psychotherapy codes, you must ensure that the time spent in psychotherapy in your documentation aligns with the add-on psychotherapy code in session details (i.e., 90833 (16-37 minutes), 90836 (38-52 minutes), 90838 (53+ minutes)). |
Guidance When billing add-on psychotherapy codes with E/M services, documentation must clearly separate the time spent on each. Psychotherapy time should occur within the total session time but must not overlap with the time used for E/M activities. For example: Total session time: 10:00 AM – 11:00 AM / Psychotherapy time: 10:20 AM – 11:00 AM (This means 10:00 AM – 10:20 AM was used for E/M.) The documented time must match exactly with the time entered during session confirmation. Resources |
| Allergies | Note is missing documentation of patient allergies or the lack thereof (medication or environmental). Documenting adverse reactions only is insufficient. |
Guidance Documentation must include client allergies or ‘No Known Allergies’ (NKA) for medications, food, and environmental factors. Clearly noting this prevents allergic reactions, reduces legal risk, and supports coordinated care. Resources
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| CPT code | Start and stop time do not indicate a duration appropriate for the selected CPT code. |
Guidance All CPT codes must be reflective of the services rendered and supported by documentation. Psychotherapy services are billed according to the time spent face-to-face in session with the patient. Resources |
| Service documented does not support the selected CPT code. |
Guidance Therapist: All CPT codes must be reflective of the services rendered and supported by documentation. Psychotherapy services are billed according to the time spent face-to-face in session with the patient. Prescriber: When billing E/M codes without add-on psychotherapy, time can determine the service level. Time reflects the total face-to-face and non-face-to-face care on the encounter date, including:
Ensure your documented time aligns with the appropriate E/M CPT code. When billing with a psychotherapy add-on code, the appropriate E/M code must be selected based on the level of Medical Decision Making (MDM), not time. Resources
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| Note is missing medically appropriate history and/or examination for this CPT code. |
Guidance For intakes and new patient appointments, documenting the Past Medical History (PMH) is required. What to Include: ✔ Medical conditions (e.g., diabetes, hypertension, seizures) ✔ Surgeries or hospitalizations (especially psychiatric admissions) ✔ Family history of mental or medical conditions (if relevant) Resources
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| Documented risk | Note is missing documentation of a risk assessment (i.e., documentation of SI/HI or the lack thereof). |
Guidance Risk Assessment: Patient risk must be assessed in the documentation for each session. You may use a formal risk assessment tool of your choice or you may address risk more generally (e.g., “patient denies SI/HI” or “patient endorses passive SI with no plan or intent - reviewed safety plan”). Resources |
| Dx consistency | Symptoms are not documented or are inconsistent with the diagnosis entered in session details. |
Guidance The symptoms documented in the note do not support the billed diagnosis. Please ensure that the diagnosis aligns with the clinical presentation and is supported by the documented assessment. If the current diagnosis is accurate, consider adding relevant symptoms or clinical findings to justify it. Resources
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| Interactive complexity | Note does not include sufficient justification for 90785 - interactive complexity. |
Guidance When billing the interactive complexity code (90785), documentation must clearly identify the specific barrier (e.g., maladaptive communication, caregiver behavior, language issues) and describe the additional actions taken to address it. Simply restating the code guidelines is insufficient; provide an overview of the unique circumstances justifying the use of this code. Resources |
| Interventions used | Missing documentation of specific therapeutic interventions used in session (e.g., CBT, DBT, etc.). |
Guidance You must specify the evidence-based psychotherapy techniques or interventions employed during the session, such as "Utilized cognitive-behavioral therapy techniques to address maladaptive thought patterns." If complementary or alternative practices (e.g., art/music therapy) are used, they must be paired with an EBP to be covered by insurance. Ensure all techniques and their therapeutic purposes are clearly documented to meet payer requirements and support accurate billing. Resources
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| Invalid note | Note does not contain clinical information (e.g., note is blank, lacks clinical specifics, is for referral, etc.). |
Guidance Incorporate distinct person-centered details about the client in your documentation. This can include direct relevant quotes and phrasing by the client. Document changes in symptoms, progress toward goals, or new challenges discussed during the session. Avoid generic notes: Phrases like “patient is doing well” without further detail do not demonstrate the patient’s individual progress or clinical picture. Tailored documentation shows that treatment is individualized, enhances patient care, supports accurate billing, and ensures legal compliance. Resources |
| Note failed to load (e.g., file is password protected, corrupted, etc.). | No further guidance / resources. | |
| Patient on claim does not match patient in the documentation. |
Guidance All patients’ names and dates of birth in your documentation must match the names and dates of birth in Headway's system. This is critical for insurance billing purposes. Resources |
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| Provider on claim does not match provider in the documentation. Rendering provider and billing provider must match. |
Guidance It’s come to our attention that your practice is billing for services of unlicensed clinicians (often referred to as “incident-to” billing) under the NPI of a licensed clinician. While some states and payers may permit incident-to billing under a licensed behavioral health clinician (including NPs / PMHNPs in certain jurisdictions), this practice is not operationally supported at Headway. Each clinician must render services under their own name and credentials. Resources
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| Document is not a completed progress note (e.g., note is in draft state). |
Guidance For Headway, a complete provider signature must include the provider’s first name, last name, credentials, and the date signed. If using an electronic signature, it must also include a statement such as “signed by” or “electronically signed by.” Resources |
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| Document is illegible and cannot be reviewed (e.g., screenshot of an EMR, handwritten note, etc.) |
Guidance Please ensure that all parts of your notes are legible and easily understandable by anyone reviewing them. Resources |
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| Place of service is not allowed at Headway. Unsupported locations include Inpatient Hospital (POS 21), Skilled Nursing Facility (POS 31), Emergency Room (POS 23), and Other Institutional Settings (e.g., psychiatric hospitals). Audio only sessions are not allowed in most circumstances. |
Guidance Headway and Payers adhere to CMS and AMA coding standards, the place of service must reflect the patient’s location at the time of service. Outpatient codes (11, 02, 10) cannot be billed when a patient is receiving inpatient or residential care. Those services are billed by the facility, not the outpatient provider. Resources |
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| Service provided is not allowed at Headway or no service was provided. We can only bill for Evidence-Based Practices. If using Complementary and Alternative Medicine (CAM) Treatments, you must use an Evidence-Based Practice in conjunction. |
Guidance Service is not currently supported by Headway. These services need to be billed off platform to the relevant payer and/or by patient self-pay until further notice. Resources
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| Medications | Documentation is missing a comprehensive list of past and/or current medications, including both prescription and over-the-counter drugs. You must include full medication names (no abbreviations). If you prescribed the medication, documentation must also include the dosages and frequencies. If the patient has not taken any medications historically, or currently, this must be documented in a statement. |
Guidance Your documentation must include a comprehensive list of medications you are actively managing, specifying the names, dosages, and frequencies. Additionally, it should reflect any changes made during the session and, if applicable, past medications and those managed by other providers. Resources |
| Mental status exam | Note is missing documentation of a full mental status exam. |
Guidance Documentation must include at least 5 elements of the mental status examination (e.g., affect, appearance, behavior, mood, orientation, speech, thought content, thought process). Resources |
| Patient details | Note is missing patient identifying details on every page. Note must include the patient's legal name and DOB on every page. If applicable, clarify the relationship between the preferred name, legal name, and name on insurance. |
Guidance The patient's full legal name and date of birth must be included on every page of your documentation. Preferred Name Usage: Providers may document a patient’s preferred name within the note but must always reference the legal name and date of birth for compliance and billing purposes. Example: “The patient's legal name is Johnathan Smith, but they prefer to be called Shelby Smith.” This approach allows providers to maintain accurate records while respecting patient preferences. Resources
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| PDMP check | Note is missing documentation that the PDMP was checked for the controlled substance prescription. |
Guidance When prescribing controlled substances, your documentation must confirm adherence to your state’s Prescription Drug Monitoring Program (PDMP) regulations. Resources |
| Person-centered detail | Note is missing person-centered details unique to patient (such as behavior description or quotes). |
Guidance Incorporate distinct person-centered details about the client in your documentation. This can include direct relevant quotes and phrasing by the client. Document changes in symptoms, progress toward goals, or new challenges discussed during the session. Avoid generic notes: Phrases like “patient is doing well” without further detail do not demonstrate the patient’s individual progress or clinical picture. Tailored documentation shows that treatment is individualized, enhances patient care, supports accurate billing, and ensures legal compliance. Resources
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| Physical health history | Note is missing documentation of past medical/physical exam history or the lack thereof (e.g., prior or current illnesses/diseases, treatments, injuries, surgeries, long term effects from illness, etc.). |
Guidance For intakes and new patient appointments, documenting the Past Medical History (PMH) is required. What to Include: ✔ Medical conditions (e.g., diabetes, hypertension, seizures) ✔ Surgeries or hospitalizations (especially psychiatric admissions) ✔ Family history of mental or medical conditions (if relevant) Resources
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| Progress | Documentation does not show whether the patient is improving, not improving, or staying the same. |
Guidance Your documentation must assess whether the client’s symptoms are improving, worsening, or maintained, providing a clear picture of their clinical presentation. Detail any significant changes in symptoms, including their impact on functioning and response to treatment, to ensure an accurate and comprehensive record. Resources |
| Progress summary | Note is missing documentation of treatment plan goals and/or progress towards those goals. |
Guidance Your documentation must specify the treatment plan objectives addressed in each session and detail the corresponding progress made. For example: Instead of, “Tom is making progress toward his goals.” Document, “Tom made progress toward his treatment plan goal of managing social anxiety, as evidenced by two successful public outings where he practiced mindfulness and breathing techniques.” This level of detail ensures accurate documentation of progress and aligns with treatment goals. Resources
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| Psychiatric history | Note is missing documentation of psychiatric history or the lack thereof. |
Guidance Ensure that a full history of mental health diagnosis and treatment, including therapy, medication, and hospitalization, as well as any history of self-harm, suicide attempts, or trauma. Resources
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| Psychosocial history | Note is missing documentation of patient's psychosocial history (can include background, social support system, culture and religious background, legal history, trauma/abuse history, etc.). |
Guidance Including a psychosocial history in all intakes, assessments and new patient E/M visits ensures a comprehensive understanding of the patient, leading to personalized treatment plans, improved outcomes, and compliance with billing and regulatory requirements. Key elements to include:
Thorough documentation of psychosocial history provides the context necessary for tailoring treatment to the patient’s unique needs and supports the medical necessity of services. Resources
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| Rx adherence | Note is missing documentation of patient adherence and counseling about risks of the medication prescribed / monitored. |
Guidance When prescribing medication, documentation must address risks, benefits, adherence, and patient education, including the importance of following the prescription, potential side effects, and drug interactions to ensure safe and effective treatment. Resources |
| Separate psychotherapy section | Note is missing a separate section for the psychotherapy add-on code (outside of E/M note) that includes 1) identified issues, 2) interventions used, 3) psychotherapy treatment plan/goals, and 4) progress towards plan/goals. |
Guidance When billing add-on psychotherapy codes, your documentation must include a separate section detailing the therapy portion of the session. This should cover:
For clarity, place this section at the end of your note (after the plan, before your signature) to distinguish it from the E/M portion. Clear separation ensures compliance and accurate reimbursement. Resources |
| Session details | Session duration and/or start-stop time in the documentation does not match session duration and/or start-stop time entered in session details, or is inconsistent throughout documentation. |
Guidance Documentation must include the exact start and stop time or the total duration (in minutes) of the session. If you’re using a separate EHR, the documented time must match exactly with the time entered during session confirmation. Any mismatch can lead to billing compliance issues. Resources |
| CPT code in the documentation does not match CPT code entered in session details or is inconsistent throughout documentation. |
Guidance A CPT code must be included in documentation and match the CPT submitted at session confirmation. Resources |
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| Date of service in the documentation does not match date of service entered in session details or is inconsistent throughout documentation. |
Guidance A complete date of service (month, day, and year) must be included on all documentation and match the date of service provided at session confirmation. Resources |
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| Diagnosis in the documentation does not match diagnosis entered in session details or is inconsistent throughout documentation |
Guidance The diagnosis recorded when confirming the session in the system must match the diagnosis identified and supported in the patient's documentation. Resources |
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| Place of service in the documentation does not match place of service entered in session details or is inconsistent throughout documentation. |
Guidance When selecting the place of service at session confirmation (in-person or virtual), you must assure that your selection matches the place of service/mode of delivery in your documentation. Resources |
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| Signature | Note is missing attested provider signature (e.g. "electronically signed by") with date and credential. |
Guidance For Headway, a complete provider signature must include the provider’s first name, last name, credentials, and the date signed. If using an electronic signature, it must also include a statement such as “signed by” or “electronically signed by.” Resources |
| Signature window | Note is not signed within appropriate time window. Note must be signed within 72 hours of session (48 hours for Medicare and Medicaid sessions). |
Guidance Documentation should be signed and dated promptly after the date of service. Payers require notes to be signed within 72 hours of the patient encounter to ensure timely completion (48 hours for Medicaid and Medicare). Resources |
| Substance use | Note is missing documentation of substance use assessment. |
Guidance A substance use assessment should document the substances used, frequency, quantity, duration, and impact on daily functioning. It should also include any history of treatment, withdrawal symptoms, tolerance, and current medications for substance use disorder, if applicable. This ensures comprehensive care and compliance with clinical guidelines. Resources
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| Treatment plan | Note is missing documentation of a recommended course of treatment/treatment plan. |
Guidance Your documentation must specify the treatment plan objectives addressed in each session and detail the corresponding progress made. For example: Instead of, “Tom is making progress toward his goals.” Document, “Tom made progress toward his treatment plan goal of managing social anxiety, as evidenced by two successful public outings where he practiced mindfulness and breathing techniques.” This level of detail ensures accurate documentation of progress and aligns with treatment goals. Resources |