Initial assessment: clinical documentation requirements
Applies to talk therapy intake notes
Note: This resource covers documentation requirements for Initial Assessments. Progress notes (see below) differ in some areas, but the clinical guidance here applies wherever the two overlap.
| Section | Subsection | What to document | Why it's required |
| Assessment — Mental Status Exam (MSE) | Comprehensively assess and document in a clearly grouped section: attention, orientation, appearance, behavior, speech, mood, affect, thought process, thought content, memory, judgment, insight. | The MSE provides insight into the client's current condition, and the full set of elements gives a complete picture | |
| History | Past behavioral health history | Document any past history of behavioral health treatment and diagnoses. Who diagnosed / setting of any prior diagnosis. Psychiatric medications: current or not, plus prescribing provider. If none: document assessed and denied. | Establishes baseline and continuity of care, and shows the current diagnosis was formed with knowledge of prior treatment. If there is no history, documenting "assessed and denied" proves the area was addressed rather than skipped. |
Alcohol and substance use (client 12+)
| Current use: yes/no. If endorsed: substance(s), amount, and frequency. If denied or declined: document the client's response. Substances to assess: tobacco/nicotine, alcohol, cannabis, cocaine, hallucinogens, opioids, methamphetamine. | Substance use can impact a client’s diagnosis, risk, and treatment planning, and screening is an expected component of a comprehensive assessment. If applicable, documenting a client’s denial or refusal is the record that screening occurred. | |
| Family, occupational, and social history | Relevant background on family relationships, living situation, employment or school status, and social supports. Any factors impacting functioning or symptoms. If none reported: document assessed and denied. | Gives context into psychosocial elements and functional impairment that support medical necessity for the diagnosis. | |
| Trauma history | Past trauma: yes/no. If yes: type, approximate timing or life period, and current impact on functioning or symptoms. If no: clearly document that it was assessed and denied. | Trauma history can affect differential diagnosis (notably PTSD vs. adjustment vs. mood disorders) and treatment approach. | |
| Risk & Safety | Four risk domains
| For each of suicidal ideation, homicidal ideation, self-harm/NSSI, and harm to others: current presence or absence, plus any history. If any behavior is reported, document the method and approximate timeframe/date. | Risk assessment is a core standard of care in an initial evaluation, and explicit presence-or-absence documentation is what demonstrates it was performed. |
| If risk is present currently or within past 30 days | Document: plan (presence/absence), intent (presence/absence), identified victim (if applicable), method - including access to means (presence/absence), timeframe, protective factors, and overall risk level. | These elements support a defensible risk-level determination and the clinical decisions that follow from it. | |
Safety planning
| Required if the client has active SI/HI with a plan, or active ideation or a suicide attempt within the past 30 days. Develop the Safety Plan collaboratively and document the review. Include key elements: coping strategies, supportive contacts, crisis resources, means restriction. Include referrals or higher level of care, if applicable. | Document that an identified risk was actively managed, not just recorded. This is a clinical and liability standard, and a best practice for client care. | |
Abuse or neglect
| If abuse or neglect involving a current minor, elder, or at-risk adult is disclosed, document either your mandated reporter response or the rationale for why a report was not required. | Mandated reporting obligations are set by state law and vary; the note is the record of how the obligation was discharged or why it did not apply. | |
| Golden Thread | Chief complaint | The client's reason for seeking treatment: 1–2 sentences in the client's own words, and/or a brief description of current concerns or symptoms | Anchors the note to this client and this session encounter, and is the starting point the diagnosis and plan have to trace back to. |
| Diagnosis | A clear diagnosis supported by symptoms that align with DSM-5-TR criteria, including onset or duration of symptoms where required to support the diagnosis | Insurers check that each diagnosis is consistently and accurately documented, and a clinically appropriate diagnosis is a part of ethical client care. | |
| Connection to presenting problem | The primary diagnosis should connect to the presenting problem or other documented symptoms, concerns, and/or functional impairments described in the note. | This linkage is what establishes medical necessity — a diagnosis with no documented connection to presenting symptoms won't support the claim. | |
| Evidence-based treatment (EBT) | Name the EBT or therapeutic approach used (e.g., CBT, DBT, ACT, EMDR, exposure therapy) in session. Name a specific intervention or technique delivered this session. State the link between the intervention and the diagnosis, presenting problem, documented symptoms, and/or treatment goals. | Insurers need to verify which evidence-based methods were used to confirm the services provided match the CPT code billed. | |
| Plan | Expected appointment follow-up interval (when the client will be seen next) and the primary focus of the next session or ongoing treatment. | This demonstrates you are actively evaluating whether care is working, and adjusting it when clinically indicated. |
Progress notes: billing & coding documentation requirements
Applies to talk therapy and psychotherapy progress notes — 90832, 90834, 90837 — and the interactive complexity add-on 90785.
Header and session details
The details at the top of the note, and everything that has to agree with your session confirmation.
| Requirement | What to document | Why it's required |
| Start/stop times support the code | Exact start and stop times (not just duration). Face-to-face time only — no chart review or note writing. 90832 = 16–37 min · 90834 = 38–52 min · 90837 = 53+ min | Psychotherapy codes are time-based; insurers verify length matches the code |
| CPT code matches the claim | If you include the code anywhere — header, body, billing summary — it must match Headway exactly. Not required to appear at all | Audits flag any billed-vs-documented coding inconsistency |
| Date of service matches; one session per note | One standalone, unique note per billed session. Label prior-session content "historical background" or "prior history." No running multi-date lists with identical text | Claims tie to specific dates; "diary style" notes get denied |
| Place of service matches | POS in the note = POS selected on Headway | Coverage is regional; payers need the client's location |
| Telehealth modality matches | Audio-visual vs. audio-only must match session details | Some plans restrict audio-only coverage |
| Client identifiers match | Name and DOB in note = client's Headway profile. Watch nicknames and date discrepancies | Exact match confirms you're billing for the right person |
| Rendering provider matches | Bill under the provider who directly delivered the care | Headway does not support "incident-to" billing |
| Service is supported at Headway | If the code isn't supported, bill outside Headway | Headway's payer agreements cover many but not all CPT codes |
| Name + DOB on every page | Full legal name and DOB on each page; preferred name optional but legal name required | Accuracy and historical record keeping |
| Place of service is allowed | Outpatient codes (11, 02, 10) can't be billed during inpatient or residential care — the facility bills those | Coverage is regional; payers need the client's location |
Clinical content
The body of the note: what you observed, what you assessed, and what you did.
| Requirement | What to document | Why it's required |
| Documentation supports the CPT code | Type, format, and duration must align. 90832/90834/90837 need documented psychotherapy — not care coordination, case management, or phone check-ins. If format changed mid-session (partner/parent joined), document it and bill the matching code | Payers confirm services rendered match the code's type and level of care |
| Interactive complexity (90785) | The communication barrier (maladaptive communication, caregiver behavior, severe emotional dysregulation), what you did about it, and the circumstances it created (disrupted treatment, redirection, added time) | 90785 pays extra, so payers verify it's warranted |
| Person-centered detail | Specifics from this session; consider direct quotes. Client is doing well could apply to anyone | Shows care is tailored to this client and this session |
| Interventions used | Name the specific intervention (CBT, DBT, MI) and what it addressed. "Provided supportive therapy" is too vague | Payers verify the evidence-based methods match the code billed |
| Course of treatment + progress | Recommended course/plan/goal plus a statement on progress. If the client isn't progressing, say so | Shows you're actively evaluating and adjusting care |
| Diagnosis matches | Diagnosis entered on Headway = note, consistent throughout | Payers check each diagnosis is consistently documented |
| Mental status exam | At least 7 core elements: orientation, appearance, speech, mood, thought process, thought content, judgment | Establishes current condition; full set gives a complete picture |
Signature
How you close and date the note.
| Requirement | What to document | Why it's required |
| Complete provider signature | First and last name, credentials, date signed. E-signatures need "signed by" or "electronically signed by" | Confirms you provided the care |
| Signed within 7 days | 7 days of DOS; 48 hours for Medicare and Medicaid | Details stay fresh |
| Licensure credentials | License type clearly present (LCSW, MD, NP) | Confirms an appropriate professional delivered care |
File and format
The file itself has to be readable and complete before it can be reviewed.
| Requirement | What to document | Why it's required |
| Note opens and renders | No password protection. Export straight from your EHR as a standard PDF; watch for corrupted or unsupported formats | Payers must be able to open the file |
| Note is legible | Typed, text-based. No EMR screenshots, no handwritten notes — type and re-sign handwritten ones first | Payers must be able to read every part |
| Completed progress note | Finalized and signed with name, credentials, and date. Not a draft, treatment plan, or intake form | Payers require a completed signed note per session |