Billable Session Note templates are used for completing session notes for a client following a billable session. Sometimes sent to funders for reimbursement. This is commonly known as a SOAP or Session Note, which staff can select unique templates for as part of their scheduled appointment.
Note:Any template selected under the Billable Session Notes must have a funder attached before it can be used for any appointment that is using that specific funder.
Non-Billable Session Note templates are used for completing session notes for a client/task following a non-billable session. Used for activities that are not attached to billable CPT codes. This can include activities such as supervision documentation, documenting care coordination, or other activities that are not traditionally billed to funders, but that the practice requires documentation for.
Note: In order to use a non-Billable report template, a client must be selected, as all notes (Billable or non-billable) are attached to the client file.
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Step | Description | Helpful Information |
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Creating a new Billable or Non Billable Report Template | Navigate to Templates and select Add New Client Report Template   Select “Billable Session Note”, or “Non-Billable Session Note”
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Customizing the Report Template | On the right side of the page, expand the selections and drag and drop the desired options into the report.  The options listed under Default are blank areas and information will need to be manually keyed in once attached to an appointment. Once an item is in place, you can click on the selection to edit the details. You can customize the label, description, value(s), mark as required, or delete the selection.  The remaining options in the builder, such as the options listed under Client, are selections that will auto-populate with the clients desired information form their profile. For example, if Client Address is selected then once the note is attached to the appointment the client address will populate as long as it has been entered into the client profile. If you want more information on how each option functions in a template and what it would look like on a finished report, see the Copy Template Builder Options Explained. resource from the previous page Once all selections have been made, click “Save” at the top of the screen to save the template or “Preview” to preview the template before saving. | Note:The following fields will be automatically loaded as a header regardless of what is placed in the session note body of the template:
If you wish to exclude the client-assigned facility/location, service, or service line from the header details refer to Omit Session Note Header Fields by Funder. Additionally, the top right corner of the note will display with the Client Name, Date of Birth, and Member ID (Client’s Insured ID). This can be altered with the Custom Header feature. Note: When selecting auto-populating fields such as billing codes, it is best practice to not mark these fields as required as they will already automatically pull in the data based on the appointment. If you chose to mark a given field required, be aware if there is blank data (such as modifiers), an error will show up until the field is filled out.
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Template Builder Shortcuts After the Template is Created | To access the shortcuts menu, select the purple lightening bolt on the right of the desired template.  The Shortcut menu allows users to Rename, Deactivate, Duplicate, Delete, and Manage Funders. To Add Funders to Existing Client Report Templates, click on the Lightning Bolt and Press Manage Funders Then select the funders you want to add to that template (use the scroll bar to see all funders) and press Update Funder List  | Several pre-loaded sample templates have been added to all newly created accounts. These can be used to reference or build off of. To customize the sample templates, it is recommended to utilize the SHORTCUTS icon and create a template duplicate to make changes to. |
FAQs
Question | Answer | Helpful Information |
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How do I add the daily data summary to an existing session note, billable or non-billable? | To add the daily data summary feature to an existing session note template, begin by opening a template. Drag and drop the daily summary field into the desired session note template by clicking on the “Client” Tab in the template builder then drag the “Daily Summary Sheet” into the template.  |
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How do I add modifiers and billing codes to a template? | To add additional billing code and modifier fields to any existing report template, begin by selecting the desired template. Then, open the right side “Billing” option. Select “Billing Code/Modifier” and then drag and drop to the desired location with the note. Users will then be able to see the billing code and any attached Modifier(s) to the appointment.  |
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Can I limit a template by code, and only have that template show up per code, or staff credential and not based off funder? | At this time no. However, the current recommendation is to list the Code or Staff credential in the name of the template. For example: Session Note 97153, or RBT Session Note 97153 |
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