How To: Add, Edit, and Delete Service Codes

Service codes, also known as Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes, designate which services were performed in a session. Currently, these codes are maintained by the American Medical Association and mandated by HIPAA and the Centers for Medicare and Medicaid Services. To search service codes, use the American Medical Association CPT Code Search.

By default, TherapyNotes includes a collection of service codes commonly used in mental and behavioral health. Additional codes can be added to fit the needs of your practice, and existing codes may be modified or deleted. We recommend setting up at least one service code for each service your practice provides, such as Psychiatry Intake, Group Therapy, or Psychological Evaluation.

Role Required: Practice Administrator, Practice Biller, or Clinical Administrator

To add a service code:

  • Click the User Icon > Settings > Service Codes
  • Click the Add Service Code button

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(A) Service Type: The Service Type corresponds with the Type selected when scheduling an appointment and affects the note template available to document the service.

(B) Service Code: If you are using this code to bill to insurance, enter a valid code in the Service Code field. Do not include a modifier in this field; modifiers are added individually to billing items. If this code is an add-on, select the This is an add-on code checkbox and read Add-On Codes for more information.

(C) Description: The Description appears on statements but is not included on claims.

Quick Tip: As long as the Description for each code is different, you may enter the same service code multiple times. This can be useful when you need to set up special billing circumstances (such as EAP billing) or when different payers have different billing requirements.

(D) Default Code: Select the Make this the default service code for <Service Type> checkbox to designate the service code as the default for the selected service type. The codes you set as default for Intakes and Sessions will be available for scheduling appointments on the client portal.

Quick Tip: For default codes that will be used for scheduling on the client portal, set up the Default Appointment Duration to reflect your availability. For example, if you see patients on the hour for 45-minute sessions, change the Default Appointment Duration to 46 minutes to prevent clients from scheduling appointments back-to-back.

(E) Standard Rate: Enter how much you normally charge for the session. TherapyNotes automatically includes your standard rate on claims, reducing the amount of time you spend on billing tasks.

  • Click the Add Service Code button

To edit an existing service code:

  • Click the User Icon > Settings > Service Codes
  • Click on the hyperlinked code
  • Edit the details of the service code as necessary. The service code itself cannot be changed.
  • Click the Save Changes button

To delete a service code:

  • Click the User Icon > Settings > Service Codes
  • Click on the hyperlinked code
  • Click on the Delete link at the bottom right corner
  • A dialog titled Delete Service Code will appear. Click the Delete Service Code button.

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