What a clean claim needs
- A completed note for the session, within the timing standard in Documentation standards. No note, no claim.
- The correct service code for what you did (for example, individual psychotherapy at the right duration). Use the codes in the PracticeOS note template. If you’re unsure which applies, ask Helen.
- Actual session time, start and end. Codes are duration-based. Document the real time.
- A diagnosis in the record that supports the service. Payers require it. It should be your clinical diagnosis, documented in the assessment.
- Modality and place of service: in-person or telehealth, and client location for telehealth.
- Your credential and NPI, which the system attaches, as long as your profile is complete.
How clients pay
Most clients are private-pay at the practice’s posted rates, with membership pricing available. Many receive superbills to submit to their own insurance for out-of-network reimbursement. Some payer relationships are in development. The front office knows the current status of each; don’t tell a client their insurance will cover you unless the front office or practice manager has confirmed it.What you never do
- Document a session that didn’t happen, or bill for one
- Round session time up to reach a higher code
- Choose a code or diagnosis for reimbursement rather than accuracy
- Alter a note after a claim is submitted, except by a dated addendum
- Discuss fees, discounts, or write-offs with a client on your own. Route to the front office; Helen decides.