Designing a Ketamine Clinic Intake Process That Actually Works

Running a ketamine clinic involves more than managing infusions. The intake process — everything from first inquiry to the first session — shapes patient outcomes, staff workload, compliance risk, and revenue cycle health. Many clinics underinvest in this step, then deal with the downstream costs: patients who arrive unprepared, chart gaps that complicate billing, and no-shows that waste chair time. This guide outlines what a well-designed ketamine clinic intake process looks like and where most clinics have room to improve.

The Four Stages of a Sound Ketamine Intake Workflow

A ketamine intake process typically has four distinct stages, and each one has failure modes worth planning for.

Stage 1: Initial Inquiry and Triage

Most patients arrive through organic search, referral, or word of mouth. The first contact — whether by phone, web form, or chat — is your triage opportunity. The goal is not to sell the program; it is to determine whether this patient is a reasonable candidate for further evaluation.

Key triage questions at first contact:

What condition is the patient seeking treatment for? (Relevant ICD-10 anchors: F32.9 for MDD single episode, F33.2 for recurrent severe MDD, F41.1 for generalized anxiety disorder)
Has the patient tried and failed at least two adequate antidepressant trials? (This is the standard threshold for treatment-resistant depression)
Is the patient currently under psychiatric or medical care?
Are there any obvious contraindications (uncontrolled hypertension, active psychosis, active substance use disorder)?

Front-desk staff do not make clinical determinations — but they can collect this information and flag it for clinical review before committing time to a full evaluation.

Stage 2: Medical and Psychiatric Evaluation

Every patient who proceeds past triage needs a documented medical and psychiatric evaluation before any ketamine administration. This should be billed using CPT code 90791 (psychiatric diagnostic evaluation) or the appropriate E/M code (99213 for established, lower-complexity visits; higher E/M codes for more complex presentations).

The evaluation should document:

Diagnosis with ICD-10 code
Medication history and prior treatment trials
Contraindication screen (cardiovascular history, hepatic function, dissociative history, substance use)
Informed consent specific to ketamine (including off-label status if using IV/IM racemic ketamine)
Treatment plan with number of planned infusions, monitoring protocol, and integration support

For Spravato patients, the evaluation must meet the FDA’s REMS program requirements, which include Risk Evaluation and Mitigation Strategy documentation and the requirement that patients are observed for at least two hours post-dose at a certified site.

Stage 3: Onboarding and Preparation

Patients who are cleared for ketamine should receive a structured preparation process before their first session. This is not optional — it is a safety and efficacy factor. A patient who arrives for their first infusion without knowing what to expect is more likely to have a difficult experience and less likely to engage productively with the material that comes up.

Preparation materials should cover: what dissociation feels like, how to work with difficult content rather than resist it, what to avoid before a session (certain foods, medications, and substances), who to contact if something feels wrong after a session, and what integration support is available. Some clinics build this into a preparation session billed under 90837 (psychotherapy, 60 min) with a therapist on staff.

Stage 4: Monitoring and Integration Handoff

The intake process is not complete when the first infusion starts. A closed-loop intake workflow includes a documented handoff to the clinical team managing ongoing care — whether that is the infusion nurse, the treating psychiatrist, or an integration therapist. This handoff should include the intake summary, diagnosis codes, and any session-specific safety notes.

Common Intake Documentation Failures That Create Billing Problems

The most common intake documentation failures that lead to billing problems include:

Missing or imprecise ICD-10 codes on the initial evaluation note
Consent forms that do not specifically mention off-label use (required for risk management and increasingly for payer audits)
Absence of prior treatment failure documentation (critical for any insurance submission, even for Spravato where medical necessity review is common)
Gap between the intake date and the first session with no documented reason

If you accept commercial insurance for any services — even if ketamine infusions are self-pay — payers can audit your entire chart. Document as if every note will be reviewed.

Staff Training Considerations

Front-desk and intake coordinators are the first clinical touchpoint for many patients, even if they are not clinicians. They need enough familiarity with the contraindication list to pause an intake when something flagged comes up, and they need a clear escalation path to clinical staff. This does not require clinical training — it requires a written protocol and regular review.

A written intake protocol also protects your practice. If a patient experiences an adverse event and your intake documentation is thin, your legal and regulatory exposure increases significantly.

Getting the Process Right Before You Scale

Many clinics run lean intake processes that work when volume is low and the provider is personally involved in every patient interaction. These processes break when the clinic grows. Building documentation-first intake habits early — before you hire your third infusion nurse — is significantly easier than retrofitting them later.

For support designing or auditing your intake workflow, reach out to our team here.

This content is for educational purposes only and does not constitute medical advice. Consult a licensed clinician about your specific situation.

Drafted by AI and reviewed by our editorial team. Last updated 2026-05-30.