When I started practicing as an NP, CPT coding was a pain and I thought it was personal, but for the last few years I’ve realized insurance companies are just purposely being a butthole to not cover anything! They are destroying healthcare and if you go on social media, some physicians have been speaking out about the issues… BUT -insurance companies can retaliate (read Dr. Elisabeth Potter’s Story) . The average person isn’t aware of this so be mindful of airing your grievances… Therefore dear providers do like the insurance companies do and move in silence… unless you have the money to fight billion dollar industries, the issues will usually fall on deaf ears. How to move in silence? Here are a few tips:
- If you get denials, etc., talk to the insurance company. Yes it’s painful but you’ll get insight on how to move forward and if you need to provide more/less documentation or services. Also, when you talk to these companies/get their names. Make it formal so they can actually take it serious.
- In the documentation, I note how the insurance or lack of coverage has affected the care or outcomes… insurances blame the providers -I put the blame back on them. I would literally write, due to the lack of coverage -patient is still affected by lack of coverage, the symptoms, the lack of adherence, etc.
- Inform the patient about what the insurance is/isn’t covering… sometimes my patients will call their insurance company to get assistance, but make sure they don’t threaten them! It is a crime to make threats and the calls are recorded.
- If I have patients that are lawyers/in politics, etc. I just nudge them or people in general to consider our fight. Also fill out surveys and attend local chapters/gatherings in your professions.
- Change the way you practice. Work smarter not harder, if someone is too high of acuity, don’t play superman. If I’m able to help great, but if not, I will refer out, it’s actually my secret weapon… I do community and private practices plus a billion other major things… I can handle high stress, but if you look at me the wrong way, I’m referring you out. I don’t care anymore. It’s not worth the headache. If things get more under control, yes I can put more humans on my plate, but until then I pass out community resources.
2025-2026 CPT Updates
I have another secret. I’ve never had an insurance denial. Over the course of my career, I’m sure I’ve seen over a 1000 patients and wanted to go over some tips that I feel are important. There are formal classes, books, conferences, etc. in the universe -but I have no time for that therefore, I may be horribly WRONG so that’s my disclaimer. Alright, I’ve covered some of these points before but I can add some context so here we go:
- For Intake Codes use 90791 (for therapy ONLY) or 90792 (for therapy and/or medications): I covered the format for an intake note) and just tailored it to your liking as long as insurances accept it or the billing company. If you start with a therapy (intake) code/90791 and then switch to prescribing meds, you’re still not technically supposed to use an intake code, I just add a medication code with a therapy code. I just wanted to note here to make sure you have ALL the proper information to bill the intake note.
- Maintain each note like an intake: so for the follow up (f/u), continue to have the CC/chief complaint, HPI (What’s being maintain or changed and the indication), review of systems (ROS), mental statues exam (MSE), any medical updates/changes, PSFH (work/school/living/housing situation), and when to follow up (RTC/return to clinic). Plus, with EACH note you have to have patient demographics, patient/provider location, time frames… I don’t use AI with my notes and THIS IS WHY. If you do each note like this (since it’s saved from the prior note), it eliminates the need to use, rely, or pay for AI. I’m also done with my charting a lot faster with no additional costs.
- Optional: I still use rating scales, but I don’t submit them in private practice (it’s not needed)…but it’s in the patient’s EMR and I make it mandatory if I’m doing FMLA. I do submit them in community health and with Athena’s EMR because it’s automatic so it’s a nice bonus that I don’t have to worry about.
- What’s in my patient’s EMR: prior medical/paperwork (PPW), labs, additional testing, GeneSite, rating scales, consents, etc. This is due to if insurances/billing companies, jobs, other clinics or someone requesting records and by law it has to be noted/secured. Also, make sure you get CONSENT before sending records/that’s also the law.
- Therapy Codes: this can be tricky but the system I use is if I’m refilling medications it’s 99213 or 99212 with the therapy code (90836/45 min) and if I didn’t refill or prescribe medications I ONLY use 90837 (60 min). The reason why this is controversial is because I’ve been reading how people try to use a therapy code and bill 99214 or 99215 –This is the problem. Even in community -I rarely use this codes… I actually haven’t used them in years because insurance will say it’s a red flag. I just don’t have time to fight the insurance company so I don’t recommend using them, but I’ve also notice how I get MORE pay (by having recurring patients) if I stick to my system. Recurring 99214 or 99215 will NOT work with insurances no matter how much you try to justify it…
- Concierge Vs. Insurances: some providers are opting out of insurances all together by providing concierge or a flat monthly/yearly rate fee.. I don’t agree with it because the patient will still have to pay for medical insurance but it’ll weed out many (poor) people. I’m also concerned about the ethics like am I obligated to give certain medications, treatment, or special privileges… even if it’s not in their best interest just because they pay me. It’s almost the same dilemma with the student paying the preceptor to pass them, despite having major red flags… However, if concierge practices give people better access to care, I super understand.
- Additional Thoughts: If you want to use fancier or very particular/rare/extra CPT codes, consider consulting a peer, a biller, or taking a class, paying for resources or help prior to this…Some providers have lost thousands using the wrong codes… I’ve witnessed it and it’s sad to see someone have a breakdown because they’re not understanding the importance of how to bill and losing money… I try to keep my billing and everything else simple but since I’m going to start doing Medicare/Medicaid, I’m using a 3rd party (billing) until I’m more comfortable in my private practice. Lastly, I wanted to note having a good EMR is essential to helping you stay on track, Valant has been awesome for me… The problem with Athena is that it’s too glitchy and confusing with medications, but the charting and patients communicating in the portal has been getting easier… I’m also using Valant for my Medicare/Medicaid patients (but there are free versions that are state specific/but again it’s more work and can be another learning curve).I also see patients in other states so having a solid EHR is essential.
Lastly, I’m aware I do a lot for free (like this website)… I could charge patients more, but I try not to and some people asked about how to charge. You can get estimates from Chat GPT for example… but overall code/charge with what you’re comfortable with and can justify. Even if I have someone in crises, which is like everyone, I don’t code 99214/99215 or up code. A list of what I don’t charge for/but may change if I get busier: no shows, FMLA/documentation, records, phone calls, consultations, Prior Auths. However, I’m updating my policy if I have to go to court or legal fees, fees for a school/students, other misc. costs, but it’s for future reference…
Here’s Chat GPT to help with charting your therapy notes/sessions:
Insurance companies scrutinize therapy documentation closely, especially if they want to deny or limit care. The goal is to show medical necessity and compliance with CPT coding rules. Here are the top factors to include when documenting therapy sessions so you’re protected in case of audit or denial:
🔑 Key Documentation Factors for Therapy Sessions
- Patient Identifiers & Session Details
- Date of service
- Start and end times (to justify time-based codes: 90832, 90834, 90837, etc.)
- Modality: in-person, telehealth (audio/video), or audio-only
- CPT code used, and any modifiers
- Reason for Visit / Medical Necessity
- Current symptoms and impairment (functional, social, occupational)
- Clear link between diagnosis (DSM/ICD code) and why treatment is required now
- Note any safety risks, relapse potential, or worsening if therapy is not provided
- Treatment Type & Techniques Used
- Identify the therapy modality (e.g., CBT, DBT, supportive therapy, trauma-focused therapy)
- Specific interventions applied in the session (e.g., cognitive restructuring, exposure hierarchy, motivational interviewing, coping skills practice)
- This shows insurers you’re delivering skilled, structured care, not just supportive conversation
- Patient Response & Progress
- Document how the patient engaged (active, resistant, avoidant, cooperative)
- Patient’s progress toward goals — even small steps
- If no progress, document barriers (e.g., external stressors, comorbidities) and adjustments made
- Treatment Plan & Goals
- State active, measurable treatment goals (e.g., reduce panic attacks from 5/week to 2/week; improve sleep from 4 to 7 hours/night)
- Update plan periodically (insurance may deny if it looks “stagnant”)
- Tie today’s session back to the overall treatment plan
- Risk Assessment (when relevant)
- Suicide, homicide, or self-harm risk: “denies SI/HI” if not present, or detailed plan/level if present
- Substance use updates
- Safety planning if indicated
- This protects you legally and shows medical necessity
- Coordination of Care / Collateral
- Note if you consulted with PCP, psychiatrist, school, family, or other providers
- Shows integration of care, which insurers value
- Homework / Assignments
- Document skills practice, behavioral experiments, journaling, relaxation exercises assigned between sessions
- Shows structured therapy and patient responsibility
- Plan for Next Session
- Outline what the focus will be (e.g., continue exposure hierarchy, review coping logs, address cognitive distortions)
- Reinforces continuity of care
🚩 Common Pitfalls That Lead to Denials
- Only writing vague notes like “talked about problems” or “patient feeling better”
- No time documented for time-based codes
- Treatment plan not updated in months
- No clear functional impairment described (insurance may say: “not medically necessary”)
- Same “cookie cutter” note every session — insurers flag patterns
📋 Example Template Flow (SOAP or DAP style)
- S (Subjective): Patient reports panic 3× this week, poor sleep, conflict at work.
- O (Objective): Affect anxious, fidgeting, logical thought, no SI/HI. 45-min session.
- A (Assessment): Ongoing GAD with panic; barriers include job stress. Patient using relaxation with some effect.
- P (Plan): Continue CBT focus on cognitive restructuring; assign thought log; next session review triggers.
👉 Insurance reviewers want to see that therapy is structured, goal-oriented, medically necessary, and progressing — even if slowly.
