BH Practice Documentation — 2026 Audit-Proof Standards

Session Note Components (10-Element SOAP)

1. Date + time + duration of session
2. CPT code + medical necessity
3. Presenting concern + subjective report
4. Objective observation (affect, behavior, mood)
5. Assessment against DSM-5-TR criteria
6. Treatment plan progress
7. Interventions used
8. Client response to interventions
9. Plan for next session
10. Provider signature + credentials + license number

Common Documentation Gaps That Trigger Audits

• Copy-paste from prior session (payer flag)
• Missing time documentation for 90837 (audit risk)
• Vague medical necessity language
• Missing progress measurement (PHQ-9, GAD-7, etc.)
• No treatment plan updates
• Late signing (over 24 hours post-session)

Compliance Frameworks

• Medicare Documentation Requirements
• Medicaid State Requirements
• Commercial Payer Requirements (per payer)
• State Board of BH standards
• Joint Commission (accredited orgs)

Revenant Care Audit Support

– KD, Revenant Care