This article covers what we look for in your annual chart review — both the clinical content of your documentation and the billing details. For how the review itself works (timing, sampling, and what happens after), see About your annual chart review.
Clinical documentation requirements
A complete initial assessment includes the following:
| Documentation area | What to include | Why it's required |
|---|---|---|
| Presenting concerns & history of present illness | The reason for the visit, ideally in the patient's words, plus onset, course, severity, and what makes symptoms better or worse | Anchors the diagnosis and treatment plan that follow |
| Psychiatric review of systems | Presence or absence of anxiety, depression, mania, and psychosis at minimum, plus other domains as clinically indicated. Distinct from the mental status exam below. | Catches symptoms the presenting concern alone might miss and shows the differential was considered |
| Psychiatric and medical history | Prior behavioral health treatment and diagnoses, current psychiatric medications with prescriber, medical history, full medication list (including OTC and supplements), and allergies | Establishes continuity of care and flags interactions that affect what's safe to prescribe |
| Substance use (patients 12+) | Current use across tobacco/nicotine, alcohol, cannabis, cocaine, hallucinogens, opioids, and methamphetamine | Substance use can shift diagnosis, risk, and what's safe to prescribe |
| Psychosocial history | Relationships, living situation, employment or school status, social supports, functional impact, and trauma history | Supports the diagnosis and the case for medical necessity |
| Mental status exam | Attention, orientation, appearance, behavior, speech, mood, affect, thought process, thought content, memory, judgment, and insight | Gives a complete, current snapshot of the patient at this visit |
Risk assessment and safety planning
Documenting that risk is present isn't the finish line — your note should also show how it was assessed and addressed.
| Documentation area | What to include | Why it's required |
|---|---|---|
| SI, HI, NSSI, harm to others | Current status and relevant history, documented separately for each | Explicit documentation is what shows the assessment actually happened |
| Plan, intent, and access to means | When risk is current or within 30 days: presence or absence of each | These details are what make a risk-level determination defensible |
| Protective factors | Supports, reasons for living, or other factors that offset risk | Balances the risk picture rather than leaving it one-sided |
| Safety planning | Built collaboratively — coping strategies, supportive contacts, crisis resources, means restriction, referrals as applicable | Shows an identified risk was actively managed, not just recorded |
| Disposition for acute risk | Escalation, emergency evaluation, or your clinical rationale for an alternative course of action when risk is significant | A safety plan alone isn't an adequate response to acute risk |
| Follow-up | How and when risk will be reassessed | Shows the plan extends past this single visit |
Example of thorough risk assessment documentation
"Patient reports increased depressive symptoms and intermittent passive SI over the past week, stating, 'Sometimes I wish I wouldn't wake up.' Denies active suicidal thoughts, plan, or intent. History of one prior suicide attempt by overdose in 2019. Denies access to firearms or stockpiled medications. Identifies family support and future goals as protective factors. Given worsening symptoms and history of prior attempt, suicide risk is elevated, but there is no current indication for emergency evaluation based on today's assessment. Reviewed and updated safety plan, including warning signs, coping strategies, crisis resources, and means restriction. Patient agrees to contact 988 or seek emergency care if unable to maintain safety. Follow-up scheduled in one week with instructions to reach out sooner if symptoms worsen."
This note documents risk and protective factors, and shows the clinical reasoning behind the disposition and the interventions used to reduce risk.
Diagnostic assessment and justification
| Documentation area | What to include | Why it's required |
|---|---|---|
| Diagnostic justification | The relevant symptoms, their duration, and functional impact, mapped to DSM-5-TR criteria, with differential considerations noted where relevant | Lets a reviewer see the diagnosis is grounded in what's in the note, not assumed from the presenting concern alone |
Your diagnosis should be traceable to the symptoms you documented — not assumed from the presenting concern alone.
Example of thorough diagnostic documentation
"Patient reports depressed mood, loss of interest, poor sleep, fatigue, and difficulty concentrating for the past six weeks, with symptoms impacting work performance and daily functioning. Denies history of mania or hypomania. Clinical presentation is consistent with Major Depressive Disorder, moderate, based on reported symptoms, duration, and functional impairment."
This names the specific symptoms, their duration, and the functional impact, and rules out a key differential (mania/hypomania) before landing on the diagnosis.
Medication management and prescribing safety
| Documentation area | What to include | Why it's required |
|---|---|---|
| Regimen and rationale | The clinical rationale for each medication, including for off-label use | Supports medical necessity and preserves your reasoning if the choice is later questioned |
| Medication regimen | Medication name, dose, frequency, and any changes made to the treatment plan | Supports accurate medication reconciliation, continuity of care, and safe prescribing |
| Risk-benefit discussion | A discussion specific to that medication, not a generic one | A blanket "risks and benefits discussed" doesn't show the patient heard what actually matters for that drug |
| Contraindications | Relevant contraindications you considered | Shows a known risk was recognized and reasoned through, not missed |
| Monitoring and follow-up | Required monitoring and your follow-up plan | Shows the prescribing decision is being actively managed, not a one-time note at intake |
Examples of prescribing safety considerations
| Consideration | Example | What to document | Why it's required |
|---|---|---|---|
| Potentially unsafe medication combinations | Combining sedating medications, or a sedative with an opioid | The specific identified interaction, relevant patient counseling, clinical rationale, and any actions taken to reduce risk or adjust treatment | Some combinations carry serious risks like respiratory depression |
| Medical contraindications to prescribing | A beta-blocker in a patient with asthma | The relevant history and how it factored into your choice | Certain medical conditions change whether, or how, a medication should be used |
| Pregnancy-related medication risks | A teratogenic medication in a patient who is pregnant or could become pregnant | Pregnancy status and the risk discussion | The riskiest exposure window often comes before a pregnancy is recognized |
| Mood destabilization with activating medications | A stimulant or antidepressant in a patient with Bipolar I | Your assessment of manic risk and whether antimanic coverage is in place | These medications can precipitate or worsen mania without that coverage |
| Medications requiring specific safety monitoring | Lithium or clozapine | The relevant labs or monitoring and your response to any out-of-range results | Narrow therapeutic windows or serious side effects make routine monitoring essential |
| Lamotrigine (Lamictal) titration | Initiating, increasing, or restarting lamotrigine | That the titration followed FDA guidance for the schedule used, with any interacting medications accounted for, any gap since the last dose, and rash counseling | Titrating too fast is one of the clearest risk factors for serious rash, including Stevens-Johnson syndrome/TEN |
| Seizure risk factors | Bupropion in a patient with a seizure history | The risk factor identified and that it was discussed | Certain medications carry a meaningfully higher seizure risk in these patients |
A risk-benefit discussion alone doesn't make a prescription safe
If a medication is contraindicated or a patient needs urgent intervention, document the clinical action you took — not just that the risk was discussed.
Example of thorough documentation: lamotrigine titration
"Starting lamotrigine 25 mg daily per FDA titration schedule (weeks 1–2: 25 mg, weeks 3–4: 50 mg, week 5: 100 mg, week 6: 200 mg). No interacting medications. Discussed the risk of serious rash, including Stevens-Johnson syndrome and toxic epidermal necrolysis, and counseled the patient to stop lamotrigine immediately and seek care at the first sign of rash."
This documents the schedule followed, interactions ruled out, and the rash risk named rather than implied.
Billing and coding documentation requirements
These requirements apply to E/M progress notes — 99202–99205 and 99212–99215 — including the psychotherapy add-ons 90833, 90836, and 90838, and interactive complexity (90785). Initial evaluations (90792) follow the clinical documentation requirements above.
See Headway-initiated billing and documentation reviews for more on billing review outside the annual chart review.
Header and session details
| Requirement | What to document | Why it's required |
|---|---|---|
| CPT code matches the claim | The code isn't required to appear in your documentation, but if you include it, it must match Headway exactly | In audits, insurers look for any inconsistency between billed and documented coding |
| Date of service matches; note covers one session | Date of service in the note matches Headway, and the note reflects a single date | Claims are tied to specific dates |
| Place of service matches | Place of service in the note matches what's selected on Headway | Coverage is regional |
| Telehealth modality matches | Audio-visual vs. audio-only matches between the note and session details | Some plans restrict coverage for audio-only sessions |
| Patient identifiers match the claim | Name and date of birth in the note match the patient's Headway details | Insurers need exact matches to confirm you're billing for the right person |
| Rendering provider matches the claim | Bill under the provider who directly delivered the care | Headway does not support incident-to billing today |
| Service is supported at Headway | If a service isn't supported on Headway, bill it outside of Headway | Not every CPT code is covered |
| Patient name and date of birth on every page | Full legal name and date of birth on every page | Improves accuracy and record keeping |
| Place of service is allowed | Outpatient codes (11, 02, 10) can't be billed during inpatient or residential care | Coverage depends on knowing where the patient was |
Clinical content
| Requirement | What to document | Why it's required |
|---|---|---|
| The note justifies the E/M level billed | Select an E/M code appropriate for time and/or complexity, and show the reasoning | Insurers want to know the level of care was justified |
| Interactive complexity (90785) is supported | Document the communication barrier and its impact | 90785 pays additional money, so insurers verify it's warranted |
| Person-centered detail | Specific detail about the patient from this particular session | Shows the note documents a particular session |
| Diagnosis matches | Diagnosis entered on Headway matches your note, consistent throughout | Insurers check consistency |
| Mental status exam | At least 7 core elements: orientation, appearance, speech, mood, thought process, thought content, judgment | Establishes the patient's current condition |
| Course of treatment and progress toward goals | A recommended course of treatment plus a statement on progress | Demonstrates active evaluation of whether care is working |
| Medications with name, dosage, and frequency | List medications with names, dosages, and frequencies, plus changes made | Vital for patient safety |
Psychotherapy add-on documentation
| Requirement | What to document | Why it's required |
|---|---|---|
| All psychotherapy content sits in a distinct section | A dedicated psychotherapy section clearly separate from medication management | Psychotherapy content should be structurally separate from the E/M note |
| Psychotherapy time supports the add-on code | Exact time spent on psychotherapy, matching the add-on code selected | Auditors can't verify therapy time from a single combined block |
| Psychotherapy time stated separately from total time | Psychotherapy duration documented separately from total appointment time | Insurers review E/M and therapy time as two distinct services |
| Symptoms and concerns addressed with therapy | Restated inside the psychotherapy section even if overlapping with medication management | Reviewers look for clear evidence therapy was performed |
| Therapy interventions used | Name the interventions (CBT, DBT) and what you addressed | Insurers need to verify which clinical methods were used |
| Therapy goals and progress toward them | Patient's therapy goals and progress, inside the psychotherapy section | Shows active evaluation of whether the approach is working |
Signature
| Requirement | What to document | Why it's required |
|---|---|---|
| Complete provider signature | First and last name, credentials, and date signed | Confirms who provided the care |
| Signed within 7 days | Within 7 days of date of service (48 hours for Medicare/Medicaid) | Keeps details close enough to the visit to be reliable |
| Licensure credentials | License type clearly present (LCSW, MD, NP) | Confirms an appropriately licensed professional delivered care |
File and format
| Requirement | What to document | Why it's required |
|---|---|---|
| Note opens and renders | Remove password protection and upload a readable version | Insurers must be able to open and read the documentation |
| Note is legible | Upload a typed, text-based version, not a screenshot or handwritten page | Must be legible to be reviewed |
| Completed progress note | Upload a finalized, signed note — not a draft, treatment plan, or intake form | Insurers require a completed, signed note to verify care was rendered |
Training and resources
The Headway Academy course catalog offers continuing education on documentation and prescribing practices. The Psychiatrist and nurse practitioner resource hub rounds up Headway Academy courses, desk references, and external trainings in one place.
Before submitting your notes
Run through both halves of your documentation.
Clinical documentation
- Presenting concern, HPI, and psychiatric ROS are documented
- Psychiatric/medical history, substance use, and psychosocial history are complete
- Mental status exam covers all core elements
- Risk assessed across SI, HI, NSSI, and harm to others, with plan/intent/means and protective factors where relevant
- When risk is identified, appropriate safety interventions, clinical disposition, and follow-up are documented based on the level of risk
- Diagnosis is traceable to documented symptoms, duration, and functional impact
- Any high-risk prescribing scenario has a documented risk discussion — and clinical action, not just discussion, where one was needed
Billing and coding
- CPT code, place of service, and telehealth modality match what's on Headway
- One note, one date, patient name and date of birth correct
- E/M level and any psychotherapy add-on are clearly justified
- Psychotherapy time documented separately from total visit time
- Note is signed, dated, credentialed, and submitted as a finalized, legible file
This document is intended for educational purposes only. It is designed to facilitate compliance with payer requirements and applicable law, but please note that applicable laws and requirements vary from payer to payer and state to state. Please check with your legal counsel or state licensing board for specific requirements.