7 Documentation Requirements You Can Apply Right Now
Here are some common questions and answers when it comes to mental health documentation requirements.
1. Question: Are notes for private pay clients the same as for insurance?
Answer:
Yes – justifying medical necessity has become the gold standard of documentation.
Yes – because documentation could be scrutinized in a board complaint.
Yes – if you or your client submits a superbill, the insurance company is still paying for the session.
No – if there is no insurance company involvement, a diagnosis is not needed.
2. Question: Is the diagnosis required on every note when it’s on the Intake Assessment and Treatment Plan?
Answer:
Yes! It’s required on every document.
- All documentation is tied back to the diagnosis.
- The diagnosis is the beginning of the Golden Thread.
- It’s how the insurance company knows what medical issue it’s paying for.
3. Question: If you opt out of Medicare as a provider, do you have to opt out again in 2 years?
Answer:
No, that requirement was dropped.
Want to opt-out of Medicare? Here’s the link to the official opt-out affidavit with Medicare.
4. Question: Why is the date of the next session a documentation requirement?
Answer:
- It shows continuity of care.
- When the client returns for the next session is part of the “plan” for treatment.
- If it’s not on the note and the client is a no-show, you cannot legally bill the client because there is no proof the client had an appointment.
5. Question: Are handwritten notes allowed?
Answer:
Yes! It’s fine to handwrite your notes. Lots of therapists do.
They must be legible.
If they are illegible, it’s like having no note at all.
6. Question: Why do we have to document the start and stop time? Why can’t we just write the amount of time we spend, like 45 minutes?
Answer:
The exact start and stop time is required. It’s now the insurance company verifies the CPT uses.
90832 (16 – 37 minutes)
90834 (38 – 52 minutes)
90837 (53 minutes +)
7. Question: Why do psychotherapists need to justify medical necessity?
Answer:
In the 1970s, psychotherapists lobbied to have mental health covered to improve access to care – and won.
- Insurance companies cover medical problems.
- They are entitled to know what they are paying for.
- They developed requirements that all providers must fulfill.
- Justifying medical necessity has become the gold standard for documentation even if you don’t take insurance.
If you want to learn documentation requirements and how to document your clinical work from intake to discharge, check out Documentation Wizard’s online training, Misery or Mastery®: Documenting Medical Necessity for Psychotherapists. You’ll learn how to translate your clinical intuition into the behavioral language required by insurance companies, while contributing to and reflecting high quality care.
I did not know that noting the date of next visit had so many important implications! Thank you 🙂
Context is so important! I find it helps make the “rules” easier to implement, though perhaps not less annoying.
thank you, would like to see more of these suggestions
katey winterholler
Glad these were helpful! More will follow in time. I write a blog almost every month.
Question: Are handwritten notes allowed?
I recently transitioned from paying for an EHR system to word document notes and I was wondering if they still need to be dated and signed as they were on the EHR system?
Thanks
Handwritten notes are fine. Many therapists still use them. Make sure your handwriting is legible. Illegible notes are the same as not having notes. Word Doc notes are also fine. They are what I use. Yes, they need to be dated and signed. You may be able to drop an image of your signature into the note, if the insurance company allows this.