A no-show is not a psychotherapy session. Do not generate a 90834 that pretends the client was in the room. Document an administrative or outreach note: who missed, how you know, what you did about safety, how the cancellation policy was applied, and how the next booked visit still meets medical necessity. Late cancels are the same pattern with a timestamp. The next clinical note has to pick up the thread, not copy-forward a session that never happened.
What payers mean by a golden thread still applies after a gap. Gaps are where “continue weekly CBT” dies on review.
Chart the missed appointment without inventing a visit
Date and time scheduled, service that was scheduled (90837, 99214, group 90853), how the miss was identified (empty waiting room, unanswered video join, voicemail 20 minutes prior).
Label the encounter type as no-show or late cancel in your EHR so it cannot be billed as a completed psychotherapy code. If your state or payer allows a missed-appointment fee, that is a billing artifact. It still is not a clinical 90834.
Do not fill SOAP boxes with last week’s MSE. Empty boxes are more honest than a cloned exam.
Record outreach and any safety check
Same-day outreach: call, message, portal. Who attempted, at what time, and the result.
Risk stratify the outreach. A stable weekly psychotherapy client who missed once gets a callback and a reschedule offer. A client with last-visit C-SSRS item 4, or a newly started benzo taper, or a clozapine patient due for ANC, gets a tighter loop: second call, emergency contact if your policy allows, and a documented decision about welfare check vs wait.
Write the words you left. “Please call the clinic today. If you are in danger, 988 or 911” is enough for a voicemail note. If they call back and you do a clinical assessment, that may be a separate billable service. Do not fold a 20-minute phone assessment into the no-show row without coding it as what it was.
Document the late-cancel policy as applied
Your policy (24 hours, 48 hours, first miss waived) should appear as applied to this patient, not as a poster on the wall.
Late cancel at 08:10 for 09:00 visit, inside 24-hour window. First miss this quarter; fee waived per clinic policy. Informed that the next inside-window cancel will bill the fee. Slot offered 7/27.
If you terminate for repeated no-shows, that is a clinical and administrative letter: remaining risk, meds remaining, where to go for crisis, and a copy in the chart. Do not “quiet close” a high-risk chart.
Write the next visit so medical necessity still holds
The rescheduled session is a new encounter. Interval history must cover the gap: “two weeks missed; panic attacks resumed on the on-ramp; did not practice exposure.” If nothing changed, say the gap and why ongoing care is still indicated (unmet goal, residual GAD-7 14, still in active taper).
Do not bill two units because you “made up” the missed hour. Do not extend 90837 by chatting about the no-show for 20 minutes unless that work is actually psychotherapy toward a goal.
If the miss itself is the clinical issue (avoidance, shame, mania, relapse), put that in Assessment and change the Plan: reminder calls, earlier slot, telehealth backup, case manager. That is how the next visit earns itself.
Sample outreach plus next-visit lines
7/20/2026 10:00 90834 no-show. Video waiting room empty at 10:10.
Outreach: portal message 10:12, call 10:18, voicemail left with 988.
Last visit 7/13: C-SSRS item 2 only, low acute risk. No welfare check.
Reschedule: client texted 14:40, booked 7/27 10:00.
7/27/2026 session (excerpt)
Interval: missed 7/20 because "I slept through it after a night shift."
No SI this week. GAD-7 13. Avoidance of on-ramp continued; no homework.
Assessment: panic disorder, still active; missed session is sleep and
avoidance, not dropout. Plan: keep weekly, set two alarms, exposure
homework rewritten for night-shift week. Medical necessity: residual
panic with work lateness, goal unmet.Questions people ask
Can I bill 90846 if the partner called about the no-show? Only if you provided a family psychotherapy service. A “he’s not here, we’ll reschedule” call is outreach.
Do I chart no-shows in a group? Yes, in that member’s chart. Do not mark them present in the shared roster to keep the numbers pretty.