3 ways to check your clinicians' notes before a payer does
Find documentation gaps first, with a sample audit, a colleague's review, or a check before signing, when a gap takes one edit, not an amendment.
Co-founder and CTO, JotPsych
Your clinicians sign their own notes. Some notes may reach a payer's reviewer next.
| Way | Who reads the note | When a gap shows up |
|---|---|---|
| Sample audit | Staff who know coding | After billing |
| Colleague's review | Another clinician | After signing |
| Check before signing | The clinician, with software flags | Before signing |
The sample audit and the colleague's review follow self-audit advice in a December 2015 Medicaid fact sheet from the Centers for Medicare and Medicaid Services. Pick the way that fits your staff and the number of notes your clinicians sign.
A sample audit each quarter
Ask your biller or another staff member who knows documentation and coding to pull a random sample of charts from one period and audit them. The Centers for Medicare and Medicaid Services (CMS) suggests you "pull every 'nth' chart," in its Medicaid fact sheet for behavioral health practitioners.
Sample audits fit your practice if you have a biller or practice manager on staff. You find gaps after billing.
A colleague's review
Have two of your clinicians read each other's charts. The fact sheet says, "Resist being the one to choose and audit your own charts," because most clinicians understand their own records even when details are missing.
Colleague reviews fit your practice if you don't have a biller on staff. You find gaps after signing.
A check before each note is signed
The federal Office of Inspector General audited Medicare psychotherapy from March 2020 to February 2021. On 60 of 216 sampled days, the record didn't document the psychotherapy time, per its May 2023 report.
In one case from June 2020, a provider billed a psychotherapy service with an evaluation and management visit, and the record showed only the total time spent. Medicare's psychotherapy payment was not allowed.
Your clinician can add a missing time with one edit before signing. After signing, the fix is an amendment, and CMS expects each amendment to show its date and author, per its Medicare Program Integrity Manual.
Office of Inspector General (OIG) report A-09-21-03021, May 2023, which counts missing signatures against Medicare guidance and the other two gaps against Medicare requirements. Missing psychotherapy time led the list, so have your clinicians state it in each note.
Have software flag gaps in each note for your clinician to review before signing. Checks before signing fit your practice if your clinicians sign many notes a week. You find gaps before signing.
JotAudit in JotPsych checks each note before your clinicians sign, against the codes billed and your practice's own documentation rules.
Book 15 minutes- Office of Inspector General, U.S. Department of Health and Human Services, “Medicare Improperly Paid Providers for Some Psychotherapy Services, Including Those Provided via Telehealth, During the First Year of the COVID-19 Public Health Emergency”, A-09-21-03021, May 2, 2023: Appendix H.
- Centers for Medicare and Medicaid Services, “Medicaid Documentation for Behavioral Health Practitioners”, Medicaid Program Integrity Education fact sheet, December 2015.
- Centers for Medicare and Medicaid Services, Medicare Program Integrity Manual, chapter 3, Rev. 13821, June 2026: section 3.3.2.5, amendments, corrections, and delayed entries.