How to Pick a Therapy Notes and Billing Software
For counselors, therapists, and other behavioral health specialists, therapy notes are an essential part of running your private practice. While many EHRs have integrated notes and documentation as part of their service, it’s important you find a practice management software that’s easy to use, HIPAA-compliant, and meets all your business needs.
What do therapy notes include?
Therapy notes include crucial information about your client’s mental health. These can range from diagnoses, treatment plans, and more. This documentation is necessary to track how their client is doing, what progress they’re making, and what they may need help with in the future.
Some examples of types of therapy notes are:
- Discharge notes
- Treatment plans
- Client diagnosis
- Psychotherapy notes
- Progress notes
- Initial intake notes
- Evaluation notes
What should a good therapy note and billing software include?
A good therapy note and billing software should include the necessary tools to help simplify your payments and documentation process. In addition, they should be seamlessly integrated with your EHR so it’s easy to use before or after your sessions.
Take a look at this list and make note of what’s important to have as part of your software.
Templates
You’ll want to make sure your EHR has a diverse set of templates to choose from. They should be simple to use, easy to access, and completely customizable to fit with your practice or specialty.
When choosing an EHR, make note of whether there are templates for:
- Progress notes
- Psychotherapy notes
- SOAP notes
- Intake forms
- Assessments
- Treatment plans
- Intake forms
Coding tools
A good therapy note and billing software will make it easy to add different types of clinical documentation codes. These could include DSM, ICD-10, CPT, and service codes. Built-in codes that auto-populate makes it easier to write treatment plans, because they save you from the hassle of manually looking codes up each time.
Make sure you can:
- Create your own custom service codes
- Edit an existing service code
- Use add-on service codes
Note organization
When it comes to managing all your notes and documentation, it should be easy to view, retrieve, and create new notes for each one of your clients. Top-rated EHRs will have a client portal as well, to help streamline intake forms and documentation for existing and new clients.
Make sure you can:
- Create progress notes that can be saved to a client’s profile
- Add and keep psychotherapy notes separate from your client’s record
- Load previous notes from past sessions
- Sign and lock progress notes when you’re finished
Electronic claim filing
If you accept insurance for your practice, it’s essential that your EHR lets you file electronic claims right from your account. You should also be able to track the status of your claims, and see whether they’ve been accepted or denied.
As you’re choosing your EHR, make sure it has the following:
- CMS1500/HCFA forms
- Automated payment report (ERA) recording
- Insurance coverage reports
Easy payment and billing options
Most billing softwares will include features that help you streamline your payment process. The best EHRs will seamlessly integrate your payment process into the rest of your workflow, so it’s easy for you and your clients to handle payment.
Make sure the EHR you’re considering has:
- AutoPay
- Integrated online payments
- Ability to generate superbills
- A secure credit card storage with the ability to process payments
Does a therapy notes and billing software need to be HIPAA-compliant?
It’s crucial that whichever therapy notes and billing software you choose is HIPAA-compliant. While many websites and EHRs may claim they’re compliant and up-to-date, it’s always best practice to double check before you sign up.
Protecting your clients’ privacy should be a top priority for your private practice. Make sure the EHR your choose has:
- Bank-level security
- Servers that are secure and monitored 24/7
- Test results to prove they are hack-proof that are updated regularly
- HITRUST CSF certification
What other features should therapy software have?
We’ve broken down some of the other features your EHR should have in the list below. Remember, there’s no one software that fits all. The top-rated ones will offer different plans so as your business scales, your software can too.
If you’re just starting out in private practice or are part-time, you’ll want to make sure your EHR has all the basic tools to streamline your business. In addition to the therapy notes and billing documentation features we mentioned above, make sure your software includes the following as well:
- A Client Portal
- Paperless intakes
- Telehealth (or the option to add it on)
- Unlimited document storage
- Live customer report
For more established practices, your software should include everything listed above, and more. See if your EHR has these essential features.
- Free appointment reminders via text, phone, or email
- Telehealth
- Secure client messaging
- Advanced documentation options
- Professional website builder
- A connected online directory to list your practice so clients can find you
Practitioners who have a group practice or a large established practice should make sure they have the ability to add other people onto their EHR. If this applies to your practice, make sure you can do the following.
- Add additional clinicians
- Add billers, schedulers, and administrators
- Add a practice manager
- Integrated Wiley Treatment Planners
How SimplePractice streamlines running your practice
SimplePractice is HIPAA-compliant practice management software with everything you need to run your practice built into the platform—from booking and scheduling to insurance and client billing.
If you’ve been considering switching to an EHR system, SimplePractice empowers you to streamline appointment bookings, reminders, and rescheduling and simplify the billing and coding process—so you get more time for the things that matter most to you.
Try SimplePractice free for 30 days. No credit card required.