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.
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.
Looking for a Clearer Way to Document Your Clinical Work?
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®: Essential Documentation Training 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.
Beth Rontal, LICSW, a private practice therapist and the Documentation Wizard® is a nationally recognized consultant on mental health documentation. Her Misery and Mastery® trainings and accompanying forms (in English and Spanish) are developed to meet strict Medicare requirements. Beth’s Documentation Wizard training program helps clinicians turn their clinical skill and intuition into a systematic review of treatment that helps to pass audits, protect income, maintain professional standards of care, reduce documentation anxiety and increase self-confidence. Beth’s forms have been approved by 2 attorneys, a bioethicist, and a billing expert and have been used all over the world. She mastered her teaching skills with thousands of hours supervising and training both seasoned professionals and interns when supervising at an agency for 11 years. Her newest initiative, Membership Circle, is designed to empower psychotherapists to master documentation with expert guidance, efficient strategies, and a supportive community.
