QUESTION: Can You Combine the Intake Summary and the Diagnostic Session Note? My EHR combines the Intake Summary and the Diagnostic Session Note … Read More about Can You Combine the Intake Summary and the Diagnostic Session Note?
Documenting Medical Necessity
- Protect Your Income. Pass Audits.
- Maintain Professional Integrity.
- Reduce Your Anxiety
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Misery or MasterySM
Documenting Medical Necessity
… teaches a set of skills combined with concrete tools that turn you into a Documentation Wizard!Explore using Master Forms
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Praise for Documentation Wizard
Therapists from Boston to Kaua'i have participated in live or online workshops and use Documentation WizardSM Master Forms in their practices. They have a few words to say ...
Tonight, for the first time in about 4 months (since I first started panicking that I didn’t know what I was doing), I am going home with my notes completed and all my files tidied up and put away. They have been a hot mess of “THINGS THAT I HAVE TO DO!” Your time with me really encouraged me in so many ways and helped me to consider that I do know what I’m doing and that, while there is room for improvement, there is no house on fire situation to be dealt with. You were calming, clear and able to see the integrity of my intent and speak to specific things to adjust to help me do a great job in showing up for my clients.
Rosie Best, MSW, LISW-S
Empire BC/BS conducted an extensive audit of nine of my patients and found my documentation “great,” adding that I had done a “wonderful job of documenting billed services.” The main focus of the audit seemed to be coding practices, specifically my use of 90837. No clawback and no pre-payment review ensued thanks to Beth’s stellar instruction and forms. I am especially grateful to Beth for suggesting succinct, effective ways of demonstrating “medical necessity” and keeping me calm and centered through this anxiety-inducing process.
A.F., PhD, LP
I am in the middle of taking your course and LOVING it. I didn't realize documentation could be so easy! Taking your course, I am FINALLY able to conceptualize my clients in a way that is organized and makes sense. I've been a therapist for 7 years and have worked in community mental, psychiatric hospitals, and private practice. Writing notes, treatment plans, and paperwork has been confusing, and I've often found most supervisors and directors don't have the training or the tools to give guidance on how to write them. Your training program is helping me to feel more confident in my clinical skills and in passing audits. I really can't thank you enough and highly recommend your course to anyone!
"Tonight, for the first time in about 4 months (since I first started panicking that I didn’t know what I was doing), I am going home with my notes completed and all my files tidied up and put away. They have been a hot mess of “THINGS THAT I HAVE TO DO!” Your time with me really encouraged me in so many ways and helped me to consider that I do know what I am doing and that, while there is room for improvement, there is no house on fire situation to be dealt with. Thank you, thank you, thank you!"
Rosie (Rosemary) Best, MAT, LISW-S
In January I received notice of a Medicare audit of 40 claims (for 90834). I am in Florida. I got the results today - 0% error rate and no clawback. I used Beth's forms. Just wanted to share this good news with everyone. Thank you Beth Rontal for simplifying the process. The auditor had nothing to say except 'keep up the good documentation.' Yay!!
Linda Brant, Ph.D.
I've begun using a couple of your forms for maybe the last 2 weeks and I must say, they've been quite helpful. My session notes force me to be shorter, sweeter and to the point; and I even finished a few of them in a few minutes, which surprised me. The intake form is also good for the same reason, and it covers many bases. I've yet to use the others, so time will tell with those. But so far, so good. Thank you again for giving me the privilege to access them. I appreciate it greatly.
I took your documentation course and created a session note template in my EHR based on the clinical forms I purchased from you, and guess what! EVERY. SINGLE. NOTE. done before the next session starts! Total game changer! THANK YOU!!!!
Holly S, LCSW-R
I was really impressed with your training and your forms are fabulous. They are most helpful because you present best practice from both clinicians’ and auditors’ perspective.
Aliexo Christie, LCSW
Thanks so much Beth! I appreciate all your work over the years and have implemented all your recommendations from your training.
Korah Hoffman, LMSW, MPA
I finished the training and downloaded all the forms— all I have to say is THANK YOU. I struggled with other tx plans’ simplicity and “one size fits all” of electronic platforms. I know this was an investment, but an investment for peace of mind.
Ana Barend, MAClinical Mental Health Counseling
I wanted to personally thank you so much for your training, admin forms and clinical notes! I will no longer be turned into insurance for complaints because everything in your paperwork covers me! You are awesome! Your social media policy made me squeal with joy! I am no longer annoyed with notes and my anxiety is gone as promised! I am enjoying therapy again and way more focused on treatment. Your forms and training literally made me not want to give up practicing what I love! I’m so glad I took your training. Keep up the good work!
Lisa Calderwood, LCSW
Emily Leadholm, LICSW
In her lucid, straightforward way, Beth helps participants translate what they do into the language of medical necessity, treatment models, goals and progress and shows how to document it all; a very worthwhile experience.
Spencer Nineberg, LICSW
I just went through a 2nd phone review with UBH. It sure made a difference feeling well versed in what they are looking for. We met criteria and got approved to continue with weekly sessions. Thank you for a wonderful group experience.
Diane Cohen, LICSW
Just a quick thank you for the workshop. I am a convert to your system. I just completed an assessment aka Rontal style and am using your session notes.
Greta Averbach, LICSW
I want to thank you for a Sunday workshop that I was dreading. I thought it was going to be dry and boring with me feeling like I would want to leave asap. Instead, your presentation and warmth made the experience enjoyable. Hard to believe but true! I will highly recommend the workshop.
Caryn Mushlin, LICSW
The training was fantastic and I found it at a time when I started to understand that narrative case notes were inadequate to current health insurance standards. Beth helped us all relax and then walked us through a thorough case based record system that is easy to use after the training and is fully HPPA-compliant. The record docs are now at my fingertips through the encrypted cloud and I have every confidence that they will protect me from any audit in ways that make my previous session narratives look practically foolish. Thanks you again, Beth!
Terry Hunt, EdD.
Medicare completed my audit and found no errors — no fine, no claw back. I take this as a reflection on the excellent documentation forms you offer. Apparently your session template, and the one for writing a treatment plan—both of which I have been using for a couple of years since you taught me how to complete them, impressed the auditors favorably. I hope you take this audit result as the feather in your cap that it truly is!
Meet Beth Rontal, LICSW
Beth Rontal, MSW, LICSW, is a nationally recognized and engaging speaker on mental health documentation for private practice clinicians and those in agency settings. She mastered her teaching skills with thousands of hours supervising and training clinicians at an agency for 11 years. Her Misery & Mastery® trainings and documentation forms have been used world-wide. Beth works with both emerging and seasoned mental health professionals, agencies, clinics, and group practices. Beth writes blogs on clinical documentation, co-chairs the NASW Private Practice Shared Interest Group, and has a private practice in Brookline, MA specializing in working with people who struggle with emotional eating.
Hints and tips to help you improve documenting medical necessity
Should I Document Medications on Progress Notes?
QUESTION: Should I Document Medications on Progress Notes? I have heard from others, who consider themselves Medicare documentation experts, that … Read More about Should I Document Medications on Progress Notes?
Mental Health Documentation for Workman’s Compensation
Mental Health Documentation for Workman’s Compensation A therapist recently asked me how to document for a Workman’s Compensation claim. Some … Read More about Mental Health Documentation for Workman’s Compensation