Session Management and Documentation Expectations

Read the following page! You’ll attest to it when you submit the annual training form.

Supervisory Availability

Your specific supervisor MUST be available during any time you are ever in contact with any client in any situation.

If you know that your specific supervisor is not available, you cannot bill insurance clients for those sessions and you should not be holding the session (unless arrangements have been made for another supervisor to be available during this time as “backup”).

You cannot hold sessions if a supervisor is not immediately available to respond to crisis situations and to take over the session if needed. Cancel your session if you know that your supervisor is not available and if you know that you do not have backup. 


No initial paperwork is required to complete a consultation. All consultations should be documented and count as clinical contact time for the purposes of hours accrual toward internship/graduation.

Consultations should be scheduled in simple practice

Initial Paperwork

It is imperative that all required documentation be completed prior to beginning any session with any client ever. DO NOT hold a session with a client until all documentation has been completed in a satisfactory manner. 

No Surprise Act

For non-insurance clients, a “No Surprise Act” form must be completed, uploaded to the client’s file and shared with the client at least one day prior (and preferably three days prior) to meeting for the first time. 

If one’s fee is renegotiated or the expectations for services to be provided change (i.e., the person was in individual therapy and is transitioning to group). An updated No Surprise Act form must be completed, uploaded and shared within one day. 

This does not apply to insurance clients

Limits of Confidentiality

Limits of confidentiality must be discussed with the client at the beginning of the first session and any time it appears to be acutely relevant to the information being discussed.

Session Length

  • Insurance Clients

The standard insurance session length is 53 minutes (CPT code, 90837). 

If the client comes late, the session must be extended or be re-coded as 90834 (38-52 minutes), 90832 (16-37 minutes), or 00000 (less than 16 minutes).

Any clinician in Delve has the right to cancel the session if the client is more than 7 minutes late for the beginning of the session. However, consult with your supervisor regarding their expectations and preferences for this. You must follow your supervisor’s expectations for this. 

-Consultations should last approximately 15 minutes, have no payment requirements, and are coded as 00000.

-A session that lasts 0-15 minutes should be coded as 00000 and should have no payment requirements.

-A session that lasts 16-37 minutes should be coded as 90832.

-A session that lasts 38-52 minutes should be coded as 90834.

-A session that lasts 53-89 minutes should be coded as 90837. This is the standard.

Sessions lasting longer than 90 minutes are discussed in “Extended Sessions” below.

-Family sessions should use billing code 90847. These sessions must be a minimum of 26 minutes but are expected to be 50 minutes in length. 

  • Self-pay Clients

The standard self-pay session length is 45 minutes (CPT code, 90834). We will extend up to 89 minutes without charging any extra.

Follow the No Surprise Act form to determine the length of session and payment requirements. Do not deviate from the information provided on this form. 

If the client is more than 7 minutes late for the beginning of the session. However, consult with your supervisor regarding their expectations and preferences for this. You must follow your supervisor’s expectations for this. 

Modifier codes / Place of Service Codes

Modifier Codes

All insurance telehealth sessions must include the modifier code “95”

Students must be working toward a graduate degree or licensure in order to be seeing clients under supervision. If they are not for any reason, they cannot continue to see clients. 

Students whose highest level of education is a Bachelor’s degree should also include the modifier code, “HN”. 

Students whose highest level of education is a Master’s degree (Must be a clinical master’s degree), must also use modifier code “HO”.

Students whose highest level of education is a Doctoral degree (Must be a clinical Doctoral degree), must also use modifier code “HP” if they are unlicensed.

Client Location

If the client is not in their home: 

Do not submit the claim as is. The PoS code needs to be adjusted to 02. 

Record the client’s location (exact address) in the notes section. 

If the client is out-of-state:

Consult with your supervisor prior to proceeding. 

If the client is not in a private location: 

Consult with your supervisor prior to proceeding, but you are expected to ensure that the session is private enough that the client can speak freely. If they cannot reasonably speak freely without fear of being overheard, the session should not proceed unless the supervisor specifically indicates otherwise. 

Case Notes

Case notes are preferred to be completed on the same date in which the service was 


Case notes are expected to be completed the next day if they are not completed the same day.

Case notes must be completed within one week of the date of service. Delve reserved the right to withhold payment for services rendered in which the documentation was not completed within one week of the session date. Delve may apply this withholding retrospectively especially in the case of an insurance review and recoupment of previous remittance (A.K.A. “Clawback”).

For students, failure to complete case notes in a timely manner may be reflected in the student’s evaluation. 

Client Correspondence / Email / contact and searching

Any clinically relevant email, phone call, in-person interaction, text message, or other correspondence needs to be documented in the client’s file. A correspondence is considered clinically relevant if it may reasonably affect the client’s diagnosis, clinician’s or supervisor’s conceptualization or clinician’s or supervisor’s assessment of the client’s functioning and distress, or would reasonably affect ongoing treatment planning (beyond a cancellation or standard scheduling/rescheduling). 

You may document these correspondences by uploading a PDF to the client’s file (especially in the case of emails), by writing a chart note, or by another standard discussed with and agreed upon in collaboration with your supervisor or supervising manager. 

Do not ever befriend clients on social media platforms. (added 4/20/2022)

Do not search for information about your clients on social media platforms, the internet, or through any other means. (added 4/20/2022).

Do not meet with your clients in person without prior permission from your supervisor. (added 4/20/2022).


All letters must be saved in PDF form and uploaded to the client’s folder PRIOR to providing this letter to the client or any outside entity. 

PHI Disclosures

See the PHI disclosures training. 

Clinical Documentation (when the Client is not Present)

Adam created the DOC and PHI procedure codes for internal use only. They are not valid, billable CPT codes. DO NOT, UNDER ANY CIRCUMSTANCES, SUBMIT THESE CODES TO INSURANCE.

These codes are meant to provide a means of documenting information in the client’s medical record on a specific date when you are not actively meeting with the client. These are for internal use only.

Example DOC: You called DCFS to consult on your own (and did not disclose PHI), and you want to record their recommendations and other relevant data.

Example DOC: You consulted with a supervisor who provided material guidance that will substantially shift the your treatment plan.

Example PHI: You called DCFS to consult on your own (and DID disclose PHI), and you need to record the PHI disclosure.

Disclosure of PHI needs to be recorded in a separate PHI clinical note. This allows us to quickly identify all instances of disclosure of PHI in a client’s history. Always set it up as a separate “session” using the PHI CPT code and the “Record of PHI Disclosure” Note Form.

Billing note: When you create a DOC or PHI session, go to the client’s file –> Billing Tab –> Session Date –> Edit –> Switch to “Self-Pay” and set the dollar amount to $0.

Self-Pay Agreements (added 4/20/2022)

All clients on a self-pay or sliding scale agreement must receive a No Surprise Act Good Faith Estimate prior to the first session. This must be regularly updated especially when the initial agreement expires and/or the terms of the agreement change.

Billing (4/20/2022)

Never charge a client without their express consent to charge them for a specific amount. Their consent to charge their card in one instance is not consent to charge it again at some point in the future. Do not turn on autopay without a client’s consent.

Canceled meetings / No Shows

Consult your supervisor for their specific expectations regarding late cancellation (within 24) and no shows. This consultation should include:

Should I flag this session as “Canceled”, “Late Canceled”, or “No Show”?

Late cancelled and no show appointments incur a charge unless adjusted.

Should I charge the client?

Your supervisor determines whether clients should be charged for late cancellations and no shows. Fully licensed clinicians may make their own determination. 

Video Recording

You must ask for consent to video record any client and they must complete a video recording consent prior to recording any video. 

Videos should be deleted regularly throughout each month and all videos must be deleted when completing the quarterly review. 


In the event of a crisis, fully licensed providers should use their clinical judgment to effectively manage the crisis and to employ outside support from other clinicians and administrators as they deem appropriate. 

Supervisors must remain available throughout the day to continue to support their students and to take over the therapy session at any moment. Supervisors are expected to be contactable by phone throughout the clinical day and are expected to interrupt their own therapy sessions to support a student if the student is in need of immediate support. 

Provisionally licensed clinicians and students must include their supervisor as soon as they suspect that a session may be developing into a crisis. The first step in contacting a supervisor is to try to call them directly. All students should acquire their supervisor’s cell phone number and save this information. 

If the student cannot contact their supervisor directly, they should leave a message with the supervisor (using gchat) to inform them that they are in need of immediate support. Then, the student is expected to attempt to contact another fully licensed supervisor within the practice who can be available immediately. 

If for any reason, the student cannot reach a fully licensed supervisor within the practice, they are then expected to try to contact a supervisor at their graduate program (or any fully licensed psychotherapist they know who is licensed in this state). In the event that this occurs, the student should also inform a Delve Director after the alleviation of the crisis of the failure to reach a supervisor. Delve Directors are then expected to review the circumstances leading to this failure of supervisor availability and to complete documentation that clarifies the nature of the problem, expected adjustments to policy to avoid this failure in the future, and documents communication with both the student and their graduate program regarding this failure. 

If the student is still unable to reach a supervisor, the student is expected to contact 9-1-1 and to inform them of the active crisis and the potential need for a wellness check for the client in question. 

Deleting a client’s file 


Extended Sessions

– There are new guidelines regarding sessions longer than 90 minutes. Please speak with Adam regarding how to handle this. Extended Sessions must only be done in consultation with your supervisor and should be “medically necessary” and is typically a response to a crisis situation.

The previous guidelines for extended sessions are included below for posterity.

-A session that lasts 90 minutes – 134 minutes should be coded as 90837 with the add-on code of 99354.

-A session that lasts 135-164 minutes should be coded as 90837 with add-on codes of 99354 and 99355. This must only be done in consultation with your supervisor and should be “medically necessary” and is typically a response to a crisis situation.

-A session that lasts 165-194 minutes should be coded as 90837 with add-on codes of 99354 and 99355, 99355 (yes, list this twice). This must only be done in consultation with your supervisor and should be “medically necessary” and is typically a response to a crisis situation.

-If a session lasts longer than this, consult with Adam regarding how to bill this session.