Finalizing a Note/Session

This article applies to the Therabill custom documentation feature.  This does NOT apply to Simple Notes in Therabill.

What is finalizing a note/session?

When you finalize a note, it is the equivalent of signing the note.  The finalization of a session is you (or your therapist) telling Therabill that all of the documentation for that session is complete and should be considered the legal document.  Do not finalize the session until you are happy with all of the documentation (note templates) that you have entered for that session.  As you will see in the next section of this article, when you finalize the session, you will not be able to change the documentation (for example, daily note or progress note) for that session.

What does finalizing a note/session do?

 Finalization of a note is a Medicare requirement for EMR / EHR.  Therefore, a lot of the limitations below are due to Medicare regulations.  Several things are going to happen when you finalize the note/session.  Here are the major things that will happen when you finalize a note.

All documentation is frozen (un-editable) on the note

When you finalize a note/session, you can no longer change, add, or delete documentation to or from it (except through an addendum).  In fact, the documentation tab that is normally located at the top of the edit session form goes away.  The tab that was previously the documentation tab turns in to an addendum tab.  If you need to make any changes or edits to the documentation after finalizing, you can only do so by adding an addendum to the note.  You can add an addendum by clicking the addendum tab at the top of the edit session form.

While Therabill will still allow you to edit service codes and other billing and coding information pertaining to the session, it is strongly recommended that you add an addendum to the session whenever you make any type of change to billing and coding information.

Providers signature is added to the printed note

If you have uploaded an image of your provider's signature, then it will be added to the note whenever you print it.  For information on how to add an image of your provider's signature, please see the article Upload Image of Provider Signature or the video uploading my providers signature image.

The finalization / signature is timestamped.

The date and time that you finalized the note is recorded.  This is the signature date and cannot be altered.

The session is available for billing (optional)

Therabill does give you the ability to only have finalized sessions available in the bill insurance area.  The default for this is all confirmed sessions are available for billing.  However, if you are using Therabill as your documentation system and EMR, we strongly recommend that you change the setting to only have finalized sessions available in billing.  You can make this setting by clicking Admin in the top green navigation bar of Therabill and then clicking Defaults/Settings in the sub-navigation bar.  At the top of the Billing Defaults, you will see the option to require a finalized note for billing (under Billing Requirements).  Remember to click the Save Changes button at the top right to save any changes you make.

The session cannot be deleted

Therabill will not allow you to delete a finalized session.  That is, in addition to not being able to delete a note from the session, you are also not able to delete the session as a whole.  For other reasons why Therabill will not allow you to delete a session, please see: unable to delete a session.

How do I finalize a note/session?

You can finalize a session by opening up the edit session form for the session that you would like to finalize.  At the far top right of the edit session form, click the Finalize tab.  On the finalize area of the edit session form, click the Finalize Session button.  You will now be prompted to enter your note signature code.  Your administrative account and each of your therapists (when a provider portal is created for them) will receive a note signature code.  This note signature code is what is used to finalize the session and should be entered into the box under the Provider Note Signature Code prompt.  After you enter your note signature code, click the finalize button.  Therabill will now determine if the note signature code matches the note signature code assigned to the rendering provider of the session.  If it matches, Therabill will finalize the session for you.

Where do I get my note signature code?

The main administrative account (the username and password that you used when you created your Therabill account) as well as all providers/therapists where you have given them login ability through the provider portal (not through a user account) will have a note signature code.  The administrative account can access their code under Admin in Therabill.  The therapists can access their code by logging in through their provider portal.  For information on accessing or changing your (or your therapist's) note signature code, please see: Provider Finalize Signature Code.

NOTE:  Many members allow their therapists to log in through an administrative user account.  If this is the case, you will still need to create a provider portal login for the therapist in order for the note signature code to be generated.  Once the therapist has their note signature code, they can use the note signature code from their administrative log in as long as they are the rendering provider of the session that they are finalizing.  For information about the difference between a user account and a provider portal and how to create user accounts and provider portals, please see: Giving Others Access To Your Therabill Account.