Compliance— a Headway Guide
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Compliance and documentation
What are therapy intake assessments?
The intake assessment is your chance to get a deep understanding of your patient — and maybe connect some elements from their journey that they wouldn’t connect themselves.
“Intake assessments” might be the wrong name for such an important piece of clinical documentation. They’re not just for intake — they document the evidence that helped you come to a diagnosis and develop a treatment plan.
When you're meeting a client for the first time, you’ll need a diagnostic session to understand their background and presenting problems. But you might also want to conduct another assessment some time later if your client’s situation seems very different from where you started. (Insurance payers will typically only reimburse intake sessions once per year.)
“I conducted new intake assessments with some of my patients in 2020 a few months into the pandemic lockdown,” says Innocent Turner, Clinical Strategy and Quality Manager at Headway. “Their symptoms were different from what we’d talked about in our first session together, and different from the diagnosis we were initially working through.”
Providers tend to have the fewest questions about intake assessments — they’re one of the most structured and defined parts of clinical documentation. Insurance carriers, however, still want to see a certain level of care and attention has been given to your first session with a new client. Here’s what you need to know.
Use Headway’s free intake assessment forms
When you’re a Headway provider, you get complimentary access to built-in client intake forms designed to make onboarding new clients fast, easy, and compliant.
Learn more about Headway’s EHR features and enhanced rates today; and start seeing insurance clients in less than 30 days.
What is an intake assessment?
Your intake assessment fulfills an important role as a starting point for your relationship with a client.
It’s how you, as a mental healthcare provider, can begin to understand the current state of your client’s mental health, including:
- The client’s reason for seeking treatment
- Their past treatment history
- Any past successes or struggles with their mental health
The intake assessment is also your opportunity as a provider to get a sense of your client’s overall health, including their full background of medical conditions, medications, and allergies. It all helps to paint a more detailed picture of your patient in the event of a mental health crisis.
Many providers call the intake assessment the “bio-psycho-social assessment,” which functions like a shorthand for the key points you need to address with your client: their biological history, their psychological history, and their social history.
Intake assessments billed with 90791 or 90792 CPT codes have no documented time requirement. Typically, an intake session lasts 45-60 minutes, by most clinical standards, due to the complexity of conducting a full assessment.
Intake assessments are typically completed once per year, per client.
3 essential types of clinical documentation
A complete patient chart contains three core pieces of clinical documentation: an intake assessment, treatment plan, and progress notes.
Think of these as the “golden thread”: Your intake note should inform your treatment plan, and your treatment plan goals and objectives should be reflected in each progress note.
Here are the key details of the different types of documentation:
- An intake assessment (intake note) should be created when initiating a treatment relationship with a client, and serve to document their current state and past experiences with mental healthcare.
- A treatment plan establishes objectives and monitors progress. The plan includes a diagnosis and clearly establishes medical necessity for treatment.
- Progress notes should demonstrate a clear and comprehensive story of the client’s progress through treatment. Clear continuity of care is important — each note should lead into the next but also stand alone.
Clinical documentation is a staple of any mental healthcare practice — it’s used to clarify the purpose of your sessions, justify the billing code used, and demonstrate a good picture of the patient’s current mental state.
These standards are outlined by the American Medical Association (AMA), Centers for Medicare and Medicaid Services (CMS), National Committee for Quality Assurance (NCQA), commercial insurers, and other regulatory agencies.
Your license or a particular insurer may have even stricter requirements than those set forth here.
6 intake notes requirements
In order to fulfill the needs of insurance carriers, it’s important that your intake assessment notes contain the following requirements:
1. Session details
These easy-to-note facts are required for all documentation, including your intake assessment:
- Start and stop time
- Place of service: For telehealth sessions, include the client's location (for example: “home” or “office,” as well as a statement that the session was conducted via a HIPAA-compliance audio/visual platform)
- Date of service
- Patient name and a second unique identifier, such as their date of birth or an assigned ID number
- Provider name and credentials
2. History of present illness
For the intake note, you need to capture what caused the client to seek help and why now. This is the history of present illness (HPI), or sometimes called a “chief complaint” or “presenting problem.”3. Bio-psycho-social assessment
3. Bio-psycho-social assessment
Your intake note should contain a full medical (biological), behavioral, and social history for the patient. This is what makes it an intake note: You’re understanding the patient’s background before they started working with you.
This part of your intake note might include:
- Medical conditions
- Medications
- Allergies
- Substance use
- Their family history, including their family’s mental health histories
- Their social structures
4. Mental status exam
You should document your mental status examination of the patient’s behavioral and cognitive functioning. This might include descriptions of the patient’s appearance, behavior, alertness, reasoning, or mood.
5. Risk assessment
In order to provide the best care possible, you need to document the client’s risk of doing harm to themselves or others. The Suicide Prevention Resource Center’s list of key risk and protective factors can help guide your assessment.
6. Diagnosis-related symptom assessment, and clinical plan
The plan in the intake assessment is the clinical plan. In other words: What you, as a provider, feel is the best path forward from here. This may include your intent to complete a treatment plan in your next session.
Intake note example
Here’s an example of an intake note that meets most insurance carriers’ compliance expectations for this type of clinical documentation.
Notice how it contains all 6 of the primary requirements for a compliant note.
Client Full Name: Katie Client
Client Date of Birth: 9/9/1999
Date of Service: 3/08/2023
Exact start time and end time: 10:23am-11:20am: 57 mins
Session Location: Telehealth, patient provided consent to telehealth, service performed on HIPAA compliant software
Diagnoses:
Major Depressive Disorder, Moderate, Single episode. Chief Complaint: Katie presents to initial session with report of worsening depression over the last month. Informs therapist she was previously diagnosed in 2019, has been to therapy in the past and finds it helpful. Says she was doing well until she lost her job 3 months ago. Once she found a new job her boyfriend ended their relationship
Chief Complaint:
Patient reports difficulty falling asleep, difficulty staying asleep, depressed mood 5/7 days, denies impulsivity denies eating concerns/issues, denies avh, endorses somatic symptoms of headaches, reports "some" childhood trauma
History:
- Current medication: denies
- Developmental: normal per patient knowledge
- Family psychiatric: mother-depression, father-alcoholism, brother-"only normal one"
- Psychiatric: hx of major depression first diagnosed in 2019
- Medical: none
- Medication trials: none
- Social: "normal" social support, has good relationship with father, mom passed in 2018, 3-4 good friends "plenty" associates and co-workers
- Substance use: occasional/social use feels that she is in control of substance use
Mental Status Exam:
- Appearance: well groomed
- Attention: good
- Behavior: normal
- Memory: intact
- Mood: sad
- Affect: flat
- Judgment: fair
- Speech: normal
- Thought content: no SI/HI/AVH, no paranoia, no delusions
- Thought process: linear/logical
- Orientation: x4
Risk Assessment:
- Suicidal ideation: denies, no prior attempts, no prior gestures, +passive SI 1+yr ago
- Homicidal ideation: denies, no history
- Violent/destructive behaviors: denies, no hx
- Current Overall Risk: low risk
- Protective Factors: future oriented, help seeking, good social supports
- Static risk factors: hx passive SI, family hx of MH, childhood trauma
- Modifiable risk factors: current low mood, lack of coping skills
Assessment:
Katie presents with symptoms consistent with mood disorder, she describes her overall mood as "I have nothing to look forward to," "I feel bad for existing," and "i randomly feel like i have a lump in my throat." Described mood consistent with DSM-5 criteria for Major depressive disorder of worthlessness, feelings of guilt, she endorses sleep disturbance of difficulty falling asleep, low energy/fatigue and difficulty concentrating. Therapist helped Katie process her feelings, provided in depth psychoeducation on depression overall, and relevant symptoms that she is experiencing such as guilt and low energy.
Plan:
Therapist will utilize both motivational interviewing and CBT-Depression to help Katie learn coping skills to manage depression symptoms specifically feelings of guilt. Therapist recommends weekly sessions, Katie is in agreement with this. Next session, therapist and Katie will complete the treatment plan.
Electronically signed by: Susan Practitioner, LCSW
Note signed date: 3/08/2023
This document is intended for educational purposes only. Examples are for purposes of illustration only. It is designed to facilitate compliance with payer requirements and applicable law, but please note that the 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.
How to bill and code intake assessments
Once you’re sure your intake note documentation fulfills the expectations of the insurance carrier, you can use the CPT code 90791 or 90792 to bill for your services, depending on your license type.
It’s important to use the code that most accurately reflects the time you spent with the patient to treat their condition, and ensure that documentation for the session supports the chosen code.
Documentation of relevant aspects of client care, including documentation of medical necessity, should ideally be completed within 24 hours of visit, and no later than 72 hours.
CPT Code 90791: For talk therapists
The 90791 CPT code refers to a service where the provider performs a psychiatric diagnostic evaluation of the patient with the aim of making a diagnosis. Code 90791 is used by psychologists, social workers and other licensed behavioral health professionals.
This code should only be used once per year per client, unless otherwise clinically necessary.
CPT Code 90792: For psychiatrists and nurse practitioners
The 90792 CPT code refers to a service where the provider performs a psychiatric diagnostic evaluation of the patient with the aim of making a diagnosis. Code 90792 is used by psychiatrists and psychiatric nurse practitioners and physician assistants, because it includes medical services.
Similar to the talk therapy code above, the 90792 code should only be used once per year per client, unless otherwise clinically necessary.
Compliance and documentation
View all resourcesCompliance— a Headway Guide
How to write a mental health treatment plan
Whenever you want to change the goal of your therapy care, or the path you want to take with the client to reach that goal, you’ll want to document a treatment plan.
How to write progress notes
Progress notes are the core piece of documentation a mental health care provider should write after each session with a client, but it’s more than just a record of what happened in the session.
