The purpose of Provider Risk Management (PRM)
The Provider Risk Management team consists of certified coders, auditors, and clinicians who review progress notes and provide feedback to support documentation best practices. When a provider is placed under PRM review, we identify documentation and coding issues that need to be addressed. Our goal is to partner with providers to ensure their documentation meets compliance standards and supports accurate, timely claim processing. We acknowledge that as clinicians, coding guidelines and appropriate documentation support for billing CPT codes are not second nature, but we’re here to help provide some clarity.
Throughout the PRM process, you’ll participate in follow-up audits to confirm that the identified issues have been resolved. Please note that after receiving feedback, you do not need to make retroactive changes to past progress notes—the expectation is that all future documentation meets compliance standards.
Maintaining documentation compliance is a requirement for continued participation on the Headway platform. We have added additional resources below that include helpful articles, video courses, and guidelines associated with the feedback you received in your provider portal to help set you up for success. Through our partnership, we want providers to feel confident in their documentation practices from a billing and compliance standpoint. However, if you are unable to meet compliance standards, your case can be referred to our Quality Improvement Committee for further review, which could include termination from the platform.
Required actions to successfully pass remediation
The table below outlines key actions and expectations at each level of the remediation process. It’s designed to help you understand what’s required to demonstrate compliance and what next steps may occur if issues remain unaddressed.
These actions are based on your escalation level and the specific documentation gaps identified in your audit. While not all actions are mandatory, completing them is strongly encouraged to support successful remediation and ongoing documentation compliance. Use this chart to self-review your progress and ensure you’re meeting expectations at each stage.
For more information about next steps and review procedures, please refer to: Provider Risk Management (PRM).
Provider checklist for remediation actions and next steps
| Risk escalation level | Action | Provider checklist |
| Level 1: Self remediation | Acknowledge audit feedback in product | |
| Review and apply guidance and resources provided | ||
| Level 2: Curative Action Plan (CAP) | Sign CAP Agreement | |
| Confirm all sessions within 72 hours of delivery | ||
| Complete documentation in the platform or upload for all sessions | ||
| Level 3: Individual provider meeting | All sessions will be audited before payment | |
| Schedule a 1:1 meeting with a medical coding specialist | ||
| Confirm all sessions within 72 hours of delivery | ||
| Complete documentation in the platform or upload for all sessions | ||
| Level 4: Final review | Pass final audit review | |
| If issues persist, case will be escalated to the Quality Improvement Committee, which could result in contract termination |
Where to find your 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. You can view your audit feedback in your provider portal.
If the feedback is on your Home page
You'll see a window titled Chart Review – acknowledge feedback by [DATE]. Click on the Review feedback button to open the note.
If the feedback is on your Home page
Home page feedback expires after 15 days, but the feedback remains available in your portal at the note level. To view the feedback:
- Log in to the provider portal
- Visit your calendar
- Select sessions from the table
- Click View confirmation details
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 |
| General Documentation Guidelines applies to both talk therapists and prescribers | ||
| 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 Documented time must align with the requirements for the CPT code billed. Therapist: CPT codes must reflect the service actually provided and must be supported by the documentation. Psychotherapy codes are selected based on the minutes spent delivering psychotherapy during the session. Prescriber: When billing E/M without psychotherapy, the E/M level may be selected using total time. Total time includes all face-to-face and non-face-to-face work performed on the date of the encounter. When billing E/M with a psychotherapy add-on, the E/M code must be selected using Medical Decision Making (MDM) only — not time. 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 describe both:
Applies to codes 90791, 90792, 90832/4/7, 90833/6/8. Resources |
| Signature | Note is missing attested rendering provider signature (e.g. "electronically signed by"). |
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.” Applies to all notes. Resources
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| Note is missing provider’s credentials/licensure. | ||
| Note is missing date signed. | ||
| The note was not signed within the 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 |
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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.). |
Guidance The document could not be opened (e.g., the file is corrupted or password-protected). Resources |
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| 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. The rendering provider and billing provider must match. |
Guidance All notes and claims must match the rendering provider. It has come to our attention that services documented by one clinician were billed under a different clinician’s NPI (“incident-to” billing). While some states or payers may allow incident-to billing in certain circumstances, Headway does not support this practice. Each clinician must document and bill services under their own name, credentials, and NPI. Resources
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| Document is not a completed progress note (e.g., note is in draft state). |
Guidance A note is considered complete only when it includes a full provider signature. A complete signature must contain the provider’s first name, last name, credentials, and the date signed. For electronic signatures, it must also clearly indicate that it was electronically signed (e.g., “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 require the place of service to reflect the patient’s location at the time of care. Outpatient POS codes (11, 02, 10) cannot be used when a patient is in an inpatient, residential, or institutional setting. Those services must be billed by the facility. 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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| Dx consistency | Symptoms are not documented or are inconsistent with the diagnosis entered in session details. |
Guidance The documented symptoms do not support the diagnosis billed. The diagnosis must align with the clinical presentation and be supported by the note’s assessment. If the diagnosis is accurate, add the relevant symptoms or clinical findings that justify it. Applies to all codes. Resources
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| Session details (applies to all codes) | Session duration and/or start-stop time in the documentation does not match session duration and/or start-stop time entered when confirming session details, or is inconsistent throughout documentation. |
Guidance Documentation must include the exact start–stop time or total session duration in minutes. Any mismatch creates a billing compliance issue. Resources
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| CPT code in the documentation does not match CPT code entered in session details or is inconsistent throughout documentation. |
Guidance Including CPT codes in your documentation is optional. However, if a CPT code is documented, it must match the CPT code submitted at session confirmation. Any mismatch creates a billing compliance risk. 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. Applies to all codes. 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 details 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 ensure that your selection matches the place of service/mode of delivery in your documentation. Resources
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| Telehealth modality mismatch/inconsistent. |
Guidance Make sure your telehealth format in session details matches the one in your note (audio-visual vs. audio-only). Resources
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| Patient identifiers | 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 legal first and last name and date of birth must appear on every page of the documentation. Preferred names may be included in the note, but the legal name and DOB must always be present for billing and compliance. Example: “Legal name: Johnathan Smith; prefers: Shelby Smith.” Applies to all codes. Resources
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| Mental status exam | Note is missing documentation of a full mental status exam. |
Guidance Mental Status Exam: Documentation must include at least 5 elements of the mental status examination (e.g., affect, appearance, behavior, mood, orientation, speech, thought content, thought process). Applies to all codes. Resources |
| Person-centered detail | Note is missing person-centered details unique to patient (such as behavior description or quotes). |
Guidance Documentation must include person-centered details unique to the patient. This may include behavior descriptions, relevant quotes, changes in symptoms, progress toward goals, or new challenges discussed. Generic statements (e.g., “patient is doing well”) are insufficient and do not show individualized care or support billing. Applies to all codes. Resources
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| Medications | Medication details incomplete (name/dose/frequency). |
Guidance Every medication prescribed or managed during the encounter must include the specific name, dosage, and frequency. To ensure compliance, please explicitly list the [Name], [Dose], and [Frequency] for all medications addressed in the note. Additionally, it should reflect any changes made during the session and, if applicable, past medications and those managed by other providers. Applies to 90791, 90792, and all E/M codes (99202–99205, 99213–99215). Resources |
| Applies to talk therapists only | ||
| Progress summary | Note is missing documentation of treatment plan goals and progress towards those goals. |
Guidance Documentation must specify which treatment plan goals were addressed in the session and the patient’s progress toward those goals. Example: Rather than “Tom is making progress,” document: “Tom made progress toward his goal of managing social anxiety, shown by two successful public outings where he used mindfulness and breathing techniques.” Applies to all therapy codes (90832–90838, 90846–90847, 90853). Resources |
| Interventions used | Missing documentation of specific therapeutic interventions used in session (e.g., CBT, DBT, etc.). |
Guidance Documentation must identify the specific therapeutic interventions used in the session (e.g., CBT, DBT) and their purpose. If using complementary approaches (e.g., art or music therapy), they must be paired with an evidence-based practice to be covered. Applies to all therapy codes (90832–90838, 90846–90847, 90853). Resources
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| Applies to prescribers only | ||
| Separate psychotherapy section | Missing separate add-on psychotherapy section that includes all required content. |
Guidance When billing psychotherapy add-on codes (90833/90836/90838), your documentation must include a separate psychotherapy section distinct from the E/M note. This section must include:
ALL required content of the documentation for the psychotherapy service are not present or are not in a distinct section above or below all E/M content. Resources |
| Add on psychotherapy content | Psychotherapy code is not supported by time documented. |
Guidance When billing psychotherapy add-on codes (90833, 90836, 90838), your documentation must clearly show psychotherapy time separate from E/M time. Psychotherapy minutes must fall within—but not overlap—the total session time and must meet the required ranges for the code billed:
Psychotherapy time in the note must exactly match the time entered during session confirmation. Resources |
| Symptoms/concerns that are being addressed with psychotherapy are not present or are not in a distinct section above or below all E/M content. |
Guidance In the psychotherapy section, specify the symptoms/concerns addressed with therapy. Keep therapy documentation clearly separate from medication management and include the required therapy elements. Resources |
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| Missing therapy interventions. |
Guidance Include interventions used in session, such as CBT, DBT, etc. in a distinct therapy section above or below all E/M content. Resources |
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| Missing treatment goals and progress toward treatment goals in psychotherapy section. |
Guidance For add-on psychotherapy billing, always include a statement detailing the client's therapy goals and their progress towards them. This information must be placed in a distinct therapy section above or below all E/M content. 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 |
| Treatment plan | Note is missing documentation of a recommended course of treatment/treatment plan. |
Guidance Documentation must include a recommended course of treatment, outlining the plan going forward (e.g., focus areas, interventions to continue, visit frequency, or next clinical steps). This shows ongoing clinical direction and supports medical necessity. Example: “Plan: Continue weekly CBT sessions focusing on panic triggers; introduce grounding exercises next visit.” Resources
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