Bill Me Maybe
What is the difference between 90834 and 90837?
90834 = 38-52 minute session
90837 = 53+ minute session
What is the primary purpose of a DA?
A DA establishes initial medical necessity by identifying the client’s presenting concerns, diagnosis, functional impact, and need for treatment.
What should a progress note include about the interventions used during a session?
A progress note should identify what intervention was used, what it was targeting, and how the client responded.
What is the shorthand abbreviation for “treatment plan”?
TxP
What is a clawback?
A clawback is when a payer takes back money they already paid for a service.
This can happen after an audit or review if the payer decides the documentation did not support the service, medical necessity, diagnosis, code, or billing requirements.
What is the difference between CPT codes and diagnostic codes?
CPT codes describe service type (e.g. 90791, 90837)
Diagnostic codes indicate the condition being treated (e.g. F41.1 GAD)
Other than mental health symptoms and emotional distress, what must a DA include in order to demonstrate medical necessity for therapy?
The DA must show functional impairment — how the client’s symptoms affect their daily life, relationships, work/school, safety, self-care, or ability to function.
DHS/statute requires progress notes to be client-centered and individualized. What does that mean in practical terms?
The note should be specific to that client and that session — not generic, copied, or interchangeable. The note should sound like it could only belong to that client, on that day.
How often must a treatment plan be updated?
Every 180 days (6 months) and whenever clinically indicated
What does “medical necessity” mean?
Medical necessity means the service is clinically needed to assess or treat a diagnosable mental health condition.
It answers: Why does this client need this service, at this frequency/intensity, right now?
What is the difference between a base code and an add-on code?
A base code describes the main service provided (e.g. 90791, 90834, 90837). An add-on code describes an additional component that can only be billed with an appropriate base code (e.g. 90785).
What is the difference between a presenting problem and a diagnosis?
Presenting problem = what’s bringing them to therapy. Diagnosis = the clinical condition being treated.
What is the relationship between progress notes and treatment plans?
Progress notes should be based on the treatment plan. The treatment plan says what you are working on; the progress note shows how you implemented the plan in that particular session.
What’s wrong with this goal?: “Decrease depressive symptoms by 50%”
“50%” sounds measurable, but it isn’t meaningful unless you define what is being measured. Feelings and symptoms don’t naturally function in percentages, so it’s unclear what “50% less depressed” actually means.
If a clinician only documents a client’s progress and improvement in therapy, what is the resulting audit risk?
The chart may fail to show that therapy is still needed, creating denial or clawback risk.
What are Z-codes/V-codes and what is one way you might use them?
Z-codes/V-codes, found in the back of the DSM, describe psychosocial, environmental, or contextual factors affecting care, but are not mental health diagnoses.
DHS states that a DA is “necessary to determine a member’s eligibility for mental health services.” What does this mean in practical terms?
The DA establishes that the client clinically qualifies for covered services and that treatment is medically necessary.
What is the expected timeline for completing a progress note after a session, and what are two possible consequences of documenting outside that timeframe?
24–48 hours after the session
Risks include:
What role does a treatment plan play in the “golden thread” of documentation?
The treatment plan is the center of the golden thread: it connects the client’s diagnosis/assessment to what you are actually doing in sessions
What is wrong with this logic?: “My documentation must be fine because the insurance company reimbursed the claims.”
Most audits happen retroactively, sometimes months or years after payment. Payers initially process claims using the billing code, diagnosis, and basic claim information — not a full review of the clinical record.
What is interactive complexity (90785) and when can you bill it?
Interactive complexity (90785) is an add-on code used when the session requires significantly more complex communication or clinical management than usual.
You can bill it when specific factors complicate communication or treatment, such as involvement of parents/guardians, interpreters, child welfare/legal systems, mandated reporting, high-conflict family dynamics, or significant communication barriers.
What is an appropriate way to include a client’s self-reported historical diagnosis?
Document it as self-reported history, not as a confirmed diagnosis, unless you have assessed it yourself or have personally reviewed and verified past records.
What is a Mental Status Exam (MSE), and how is it different from clinical interpretation?
An MSE is a snapshot of how a client presents in session, typically including observations of appearance, behavior, mood/affect, speech, thought process/content, perception, cognition, insight, and judgment.
Example: “Client was tearful, speech was rapid, affect was constricted, thought process was tangential.”
Clinical interpretation (assessment) is how you make meaning of those observations.
Example: “Presentation suggests increased anxiety, emotional dysregulation, and difficulty with cognitive organization.”
What is the difference between a goal, an objective, and an intervention?
A goal is the broader outcome the client is working toward, e.g. "Improve emotional regulation skills.”
An objective is the specific, measurable step a client takes toward that goal, e.g. "Ct will use at least 2 grounding skills during moments of high distress.”
An intervention is what the therapist does to help the client get there, “Therapist will teach and practice grounding skills in session.”
What is provider upcoding? Define and give an example.
Provider upcoding is billing for a higher-level or more expensive service than was actually provided or documented
Example of upcoding: Billing 90837 for a family/relational therapy session instead of relational billing codes (90846/47) in order to receive higher reimbursement
How many DAs (90791) can be billed per year for a client on Medicaid?
For MN Medicaid, up to 2 DAs (90791) can be billed per calendar year without authorization; up to 2 additional DAs may be billed with authorization, for a maximum of 4 per year.
Can a DA be completed and billed without determining a diagnosis? Why or why not?
The purpose of the DA is to assess whether the client qualifies for services. Sometimes the outcome of that assessment is that the client does not have a diagnosable mental health condition or does not meet medical necessity for treatment.
What are psychotherapy notes, and what are three ways they differ from progress notes?
Psychotherapy notes are separate, private notes a therapist keeps for themselves about the session, often including personal reminders, reflections, or details they want to track outside the official clinical record.
Key differences:
What does it actually mean for a treatment plan to be measurable?
A treatment plan is measurable when you know what to look for to tell whether something has changed.
Clear, trackable indicators can include:
What is payer downcoding? Define and give an example.
Payer downcoding is when a payer changes a billed service to a lower-paying code because they decide the documentation does not support the original code.
Example: A clinician bills 90837, but the payer changes it to 90834 because the note does not support medical necessity for extended time.
A clinician is unsure whether a session qualifies for 90837. Beyond session length, what is the most important factor in making that determination?
The note needs to show why clinical complexity made the extended time medically necessary.
What is the name of the legal statute that defines requirements for DAs and other documentation?
Chapter 245I. Mental Health Uniform Service Standards Act
What is “record cloning,” and what are three consequences it has for clinical care, documentation, and billing?
Record cloning is copying/pasting the same or nearly identical language across notes without individualizing it to the specific session.
What is the primary requirement that must be established in relational therapy treatment plans that is not required in individual therapy?
Establish why the partner/family member’s participation is MEDICALLY NECESSARY to treat the client’s diagnosable mental health condition
Which two categories of diagnoses are most likely to prompt an audit when used incorrectly or in excess?
What distinguishes a session that qualifies for Psychotherapy for Crisis (90839) from one that is simply high-intensity or emotionally charged?
90839 is for a mental health crisis requiring immediate assessment and psychotherapeutic intervention to reduce the crisis, diminish suffering, and help restore functioning — not just a session that was emotionally intense.
What is the difference between an Adult DA Update and a full reassessment/new Standard or Extended DA, and when is each one warranted?
Adult DA Updates are used in years 2 and 3, or when clinically indicated, to update the existing clinical picture. A full reassessment/new DA must be completed every 3 years or when requested by client.
Describe in detail the four main sections of a SOAP note, including the name of each section, its purpose, and what should be included.
S — Subjective
The client’s perspective. Include what the client reports about symptoms, mood, functioning, stressors, progress, concerns, goals, or relevant updates since the last session.
O — Objective
What the clinician observes or directly assesses. Include presentation, behavior, affect, speech, thought process, engagement, MSE/risk observations, and other observable clinical data.
A — Assessment
The clinician’s clinical understanding of what is happening. Include interpretation of symptoms, progress toward treatment goals, medical necessity, risk level, clinical themes, barriers, and how the client responded to interventions.
P — Plan
What happens next. Include interventions or homework to continue, changes to frequency or level of care, referrals, safety planning steps, coordination of care, treatment plan updates, and focus for the next session.
How many therapy sessions can be billed before finishing the treatment plan? Why? What are the exceptions?
Generally, ZERO therapy sessions should be billed after the DA but before the treatment plan is complete.
Why: The treatment plan establishes what is being treated, why services are medically necessary, and how sessions connect to the client’s goals.
Exception: A session may be billed while the treatment plan is still being developed, as long as the service is part of creating the treatment plan and is documented that way.
Why is the statement “Insurance covers couples therapy” misleading in a billing context?
Insurance generally does NOT cover “couples therapy” as relationship support.
It DOES cover relational/family therapy when it is medically necessary to treat a diagnosable mental health condition for an identified client. The partner’s participation has to support treatment of that condition — not just general communication, conflict, or relationship improvement.