In Allia, a Billable Note is a structured clinical document specifically engineered to meet the rigorous audit standards of the CPT code you are billing.
While standard AI scribes often miss the nuances of behavioral health, Allia is purpose-built for the complexities of psychiatry and psychotherapy. As insurance company audits become more intensive, the burden of proof for the level of care provided has never been more important—or more time-consuming. Allia automates this defensible documentation, protecting your practice while saving you hours of manual entry.
How to Generate a Billable Note
Follow these steps to generate a note that is audit-ready and linked to your billing:
Navigate to the Notes tab and click Create.
Select Category: Choose from Diagnostic Evaluation, Psychotherapy, or Evaluation & Management (E&M).
Choose Session: Select the specific appointment for the note.
Select Data Sources: Inform the AI by selecting relevant context (e.g., Intake forms, Past Sessions). This ensures the "Golden Thread" is maintained across the patient’s history.
Understanding Billable Notes
Standard AI tools often lack clinical depth. Allia’s notes are engineered to handle specialized psychiatric data:
Compliance & Medical Necessity: Notes are engineered to meet the strict standards of the specific CPT code you are billing. They automatically frame clinical work to demonstrate the level of care required for reimbursement.
Integrated Medication Management: Allia pulls current medications from the Patient Profile and e-Prescription records. It cross-references the transcript to document adherence, side effects, and refills.
Longitudinal Clinical Context: Unlike tools that "forget" after a session ends, Allia pulls relevant data from past sessions and intake forms to create a comprehensive record.
Zero Manual Entry: Once a note is generated, the claim is automatically added to your Unbilled Services with the correct diagnosis and fee.
You can view a sample of an Allia-generated billable note here: Allia Sample Note (90792)
Note Generation Options
1. Diagnostic Evaluations (Intake)
Used for initial assessments to establish a clinical baseline.
90791 (PDE, Non-Medical): Focuses on psychiatric assessment.
90792 (PDE, Medical Services): Includes medical components of a psychiatric evaluation.
Workflow: Select Session → Data Sources → CPT Type → Add-ons → Generate Document (takes ~5 mins).
2. Psychotherapy Notes
For ongoing treatment sessions.
Formats: Supports SOAP (Subjective, Objective, Assessment, Plan) or BIRP (Behavior, Intervention, Response, Plan). Available in "Normal" or "Detailed" versions.
CPT Codes: Templates for 90834 (45 min) and 90837 (60+ min).
3. Evaluation & Management (E&M)
For medical management in psychiatric care. Includes a Code Calculator to ensure accurate coding.
New Patients: e.g., 99205 (High Complexity).
Established Patients: e.g., 99213 (Low) or 99214 (Moderate).
Add-ons: Option to attach +90833 for psychotherapy performed during an E&M visit.
Workflow: Select Session → Coding Method (Time vs. Complexity) → Fill required fields → Generate Document.
From Session to Paid: The Workflow
Conduct Session: Use Allia's HIPAA-compliant telehealth or in-person transcript tool. (A transcript is required for billable notes).
Generate Note: Select the CPT-specific template. Allia pulls in medications and history automatically.
Approve: Review and sign the generated documentation.
Auto-Bill: The claim appears instantly in your Unbilled Services with the correct diagnosis and fee schedule applied.