How to Ensure Insurance-Ready Notes for 90837 and Other Codes
Make your therapy notes insurance-ready for 90837 and related codes. See common pitfalls, required components, and how ClinikEHR templates speed up high-quality documentation.
How to Ensure Insurance-Ready Notes for 90837 and Other Codes
Great therapy isn’t enough—your documentation must clearly support medical necessity, time, and the service billed. For longer psychotherapy sessions such as 90837 (60 minutes), insurers expect completeness and consistency. Clinics in the United States, United Kingdom, Canada, Australia, and parts of Africa use ClinikEHR to create high-quality notes quickly without sacrificing accuracy.
Common Pitfalls in Therapy Documentation
- Missing time documentation or session length inconsistencies
- Vague goals or non-specific clinical interventions
- Limited evidence of medical necessity, risk, or functional impairment
- Copy-forward overuse without updates to reflect the current visit
- Missing coordination-of-care or safety planning details when relevant
Helpful references: the American Psychological Association for professional guidance, and payer documentation standards via your plan’s provider manual.
Essential Components of a 90837-Compliant Note
- Service time documented and consistent with the billed code
- Clear diagnosis and medical necessity tied to current symptoms/functioning
- Specific therapeutic interventions and patient response
- Measurable progress towards goals; update plans as needed
- Risk assessment (when applicable) and safety planning
- Coordination of care, referrals, homework, and follow-up
Related reading on our blog:
Tools That Speed Up Documentation Without Sacrificing Quality
- Smart templates that surface mandatory fields (time, interventions, risk)
- AI-assisted narrative to turn bullet points into clinical language
- Libraries of goal/intervention phrases for CBT, DBT, ACT, etc.
- Integrated rating scales (PHQ-9, GAD-7) with automatic scoring
- One-click claim prep with code validation and modifier prompts
ClinikEHR Note Templates for Therapists
- Session templates for 90791, 90832, 90834, 90837 with required elements
- Progress note helpers for measurable goals and outcomes tracking
- Risk/safety, coordination-of-care, and treatment-plan addenda
- Voice-to-text support for fast, natural documentation
- Real-time checks to align notes and claims
Frequently Asked Questions (FAQs)
What should 90837 documentation include beyond time? Evidence of medical necessity, detailed interventions, patient response, and progress tied to goals—plus risk and follow-up when relevant.
Do all payers allow 90837 every week? No. Frequency and prior-authorization rules vary. Always verify plan policies.
How can I avoid denials for longer sessions? Ensure time and content justify the service, track outcomes, and document risk/complexity. Use real-time claim checks in your EHR.
Can templates still be individualized? Yes. Templates should guide required elements while preserving clinician narrative—ClinikEHR does both.
Does ClinikEHR help with modifiers and payer rules? Yes. It surfaces prompts for common payer requirements, including modifiers when applicable.
Conclusion
Insurance-ready notes keep you paid and compliant. With the right tools, your documentation can be thorough, fast, and consistent every time.
ClinikEHR gives you 90837-ready templates, AI-assisted narrative, scales, and real-time claim checks.
Ready to make documentation easy and insurance-ready?
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