No second guessing how to document your work.
Many psychiatric NPs are delivering real therapy and doing the work — but their documentation isn't showing it. That means undercoding, missed reimbursement, and notes that don't hold up when reviewed.
It's not about the care you gave. It's about whether your documentation proves it.
Crystal Stone, PMHNP-BC, FNP-BC, CPMA, CPC, and CPB of New Leaf Billing, Coding, and Auditing Solutions, LLC, conducted an independent content review of this second edition for general alignment with documentation and coding standards.
The Psychotherapy Documentation and Coding Handbook is a practical guide to document structured psychotherapy clearly, bill accurately, and feel confident every time they sign a note.
Structure your documentation so you can:
Bill accurately for the full scope of your work
Write notes that clearly reflect your clinical reasoning
Document psychotherapy and E/M services as distinct, defensible services
Stop second-guessing every note before you sign it.
Clear breakdowns of time-based and MDM coding
Step-by-step guidance on combining E/M with 90833 and 90836
Quick-reference tables for time thresholds, billing criteria, and documentation requirements
Real note examples for 99213, 99214, and 99215 with add-on psychotherapy
Documentation template you can model in your own practice
Telehealth billing support including modifiers and place-of-service codes
Treatment plan tie-back examples to strengthen medical necessity
FAQ addressing common documentation mistakes and billing pitfalls
The Psychotherapy Documentation & Coding Handbook gives you the structure to document what you are already doing, bill accurately for the full scope of your work, and feel confident every time you sign a note.
Whether you are new to therapy-integrated practice or refining your existing workflow, this is the reference you will actually use.