In case you'd prefer to read instead of watch, here is an edited transcript of the video. Enjoy!
Wayne
I first met Beth when she was a clinical supervisor at a mental health clinic that I worked with, and I knew that she did a great job supervising the clinicians there. She worked there for 15, 16 years. And I know she helped them with record keeping, reviewing their notes, working with insurance companies and helping them avoid problems with audits. And I personally got one on one documentation training from Beth, and also attended her all day workshop, which I found incredibly helpful.
I was so impressed with her work that I invited her to speak with a CBT group that I was involved in, the CBT Study Group. She came and she talked about documentation. And so I thought it would be great for Beth to share some of the work that she does on a regular basis with folks in a national international audience that we have on LinkedIn and the Lincoln Group, and with some of the folks that we've been working with. Beth has workshops, materials, as you'll see.
These materials are second to none. She organizes materials so it's so simple to learn. And in this webinar, you'll see how she's put together some great tools and forms. And this is going to provide an organized approach that I want to share with the community. So, Beth, welcome.
Beth
Thank you. I'm glad to be here.
Wayne
So, Beth, I know that you love being a therapist. My question to you is, why did you decide to teach documentation skills and how did you learn those skills?
Beth
Well, I learned the skills because I had to as a clinical supervisor. Like you said, it was my job to review the documentation for all the people I supervised. And I've supervised over 50 people in my career and I didn't really want to learn this skill. But jobs have a way of teaching you things that you didn't know you needed to or would appreciate learning.
So I've spent thousands of hours reviewing documentation. And at one point, I was assigned a clinician who was really struggling with documentation. She was struggling for about a year and they thought perhaps I would be able to help her. I really, really wanted her to learn it and would do everything that I could to teach her so, that she could learn it and she could keep her job.
She was given three months to get current, and within a couple of weeks she did not have to see me twice a week anymore. And within three months, she was very able to do her work. And in fact, able to teach other people how to do it as well. So it was from our work together that I realized I had a knack for teaching this, that I understood it really well because I had to struggle to learn it. And now it's actually quite simple for me.
So, you know, my goal is to teach private practice therapists and therapists and agencies and any anywhere that they will listen, how to do their documentation so that it is a contribution to clinical work, so that it doesn't take forever, so they're HIPAA compliant, so they don't get hit with clawbacks or insurance companies taking money back from them. So that the work actually means something and that it's not just an annoyance. That's how I came to do documentation.
Wayne
So, Beth, why do so many therapists have a difficult time with documentation?
Beth
Well, I would say the first thing that gives them a difficult time is that they don't really know what to write. Documentation is a standard in our profession, but in social work journals, which are most of the journals I know because I'm a social worker, in social work journals, there is nothing written about clinical documentation between 1934 and 2011.
It's not taught in schools or not taught clearly in schools. So, people don't know what to write and they don't quite understand the difference between what's necessary for the medical record and what's necessary for their memory from session to session.
You know, many, many therapists resent oversight from a third party, meaning the insurance company. But the truth is, is it's here to stay. And the good news is. it's not rocket science. It's really a formula. And once you learn the formula, everything fits in very nicely.
Wayne
So from your experience, Beth, why do clinicians need to keep records? What are the sort of main reasons?
Beth
Well, besides being standard of care and protecting you from clawbacks from the insurance companies, if you get audited, keeping records actually helps you justify or prove medical necessity.
It's possible that you might have a workman's comp claim. You're working with somebody who's on Workman's Comp or your notes might be subpoenaed for some kind of legal proceedings. If you're involved, for instance, in a contentious custody battle or divorce dispute, somebody might be on disability, your client might want to see it. Another therapist or collateral contact may find it useful. So there's continuity of care.
Those are the main reasons we keep clinical reports. I find that when I write my session notes in particular, it gives me an opportunity to reflect on what happened in the session without the pressure of being there and having to come up with something or being present, so that I sometimes have insights into what happened and get ideas for what to do next. So I find that my record keeping actually contributes to my clinical work.
Wayne
So the first slide is about "medical necessity." Everybody talks about medical necessity, but no one really understands what it is. Can you give us an explanation of what medical necessity is and how to justify it, to say, the insurance companies?
Beth
Yeah. First, I'm going to give you the definition. If you would put this slide up for "what is medical necessity," so that I can see it and everybody else can see it. That would be really great. Perfect. Thank you. So I'm going to read this. And bear with me, everybody. This is the definition from Cigna. I got it off their website a few years ago when I first started teaching this. So just just bear bear with this definition.
So, "Health care service, that a health care provider exercising prudent clinical judgment, would provide to a patient for the purposes of evaluating, diagnosing or treating an illness, disease or its symptoms and that are in accordance with the generally accepted standards of medical practice, clinically appropriate in terms of type, frequency, extent, sight and duration and considered effective for the patient's illness, injury or disease.".
I hope you're all with me so far. "Not primarily for the convenience of the patient or health care provider, physician or any other health care provider, and not more costly than an alternative service or sequence of services, at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the patient's illness or disease. Now I'm going to speed up a bit generally accepted standards of medical practice and standards that are based on credible scientific evidence published in peer reviewed medical literature, generally recognized by the relevant medical community, physician and health provider Specialty Society recommendations, the views of physicians and health care providers practicing and relevant clinical areas and any other factors."
So, that is the definition of medical necessity. Most people I read this definition too don't follow it very well. I mean, if you break it down phrase by phrase, it does make sense. But operationalizing it is another story. And that's what I've done. I have operationalized the whole thing so that each of those criteria are met if you follow the process that I teach.
So. Oh, good. You've got the next slide. So medical necessity is basically a checklist. "Reduce symptoms, stabilize symptoms, maintain gains, prevent compensation, address acute symptoms, manage chronic symptoms, improve functioning, prevent higher level of care."
But this is your conclusion based on your hypothesis and what your process is. So you can't check off the box until you have justified everything that you're doing, that you've done, that leads to this conclusion. So let's go to the next slide, Wayne, which is the Golden Thread. Wonderful. Thank you. So in order to justify medical necessity, you need to write your notes so that everything refers to itself.
So here's what the Golden Thread is. "Each element in the therapeutic process from intake to discharge charge must be clearly documented so the connection between all aspects of clinical workflow logically from one record to another. Let's go onto the next slide.
If the golden thread is maintained, documentation will support each decision, intervention and note, contributing into a complete record of client care that reflects your work with integrity, is respectful of client confidentially, will pass an audit and get reimbursed by insurance companies.
In other words, you write your diagnostic summary or the intake. That informs your treatment plan and your treatment plan informs what you do in your sessions, and that informs any possible case or collateral consults, and that informs what you write when you client is discharged. So everything has to tie together. So that's the definition of medical necessity and the golden thread.
Wayne
OK, so Beth, when you presented at my CBT consultation group, you mentioned that there is a language that insurance companies require.Tell us a little bit about that.
Beth
When you take insurance, and I'm speaking directly about insurance at this point, although even if you do not take insurance, this is the formula that you should follow. You have to have authorizations every eight to 12 sessions and the authorizations are written, as are the treatment plans and even the session notes; they're written using behavioral language because you have to measure progress and change. And that makes sense to use behavioral language because how does change show up? It shows up in behavior. Right. So even if you don't do cognitive therapy or cognitive behavioral therapy, you can still document your work using behavioral language. So, even changes in thinking are a change in behavior, even changes in feeling, in feeling states are actually behavior. So a lot of people, particularly those who don't do CBT, ask me, well, how do you do this?
One of the one of my favorite questions that I ask clients when they say, "Well, I'm really depressed."
Or we identify together that they're depressed... I'll ask them, "So you said you were depressed. What does that depression make you do or not do?" And if they can't answer that, I might pull out, you know, the diagnostic criteria. And I'll say, "Well, when a person is depressed, they often feel hopeless. Does that apply to you?".
Then my client replies, "Well, yes, it does."
Beth
If this were a movie of your life and someone were watching it, how could they tell that you were depressed? And they might be able to tell you how, you know, what other people would see. And if they can't, then you pull out more diagnostic criteria. And you say, "Well, a lot of times people who are depressed have trouble with their sleep. Do you struggle with sleep problems?"
And the client replies, "I do."
Then I may respond, "Oh, well, tell me, do you do you sleep a lot? Do you wake up a lot in the middle of the night? You have trouble falling asleep?" So, then you can ask them more and more questions. If they say, "No, nobody would know that I'm depressed."
That's another problem. Then the issue is perhaps they're socially isolated, which is part of what happens with depression. They don't trust people enough to share their feelings, which also can happen with depression. "So, what does the depression caused you to do or not do? What does the anxiety cause you to do or not do? Or, if this was a movie of your life and other people were looking at it, what would they see that would make them think that you were depressed?" So that's how you can clue into the behavior.
Wayne
Yeah, that's very helpful, Beth. Now that we've done away with the multi axis system and there's no more global assessment of functioning score, what replaces it? And how do we indicate the person's level of functioning now?
Beth
OK, that's another good question. The good news about her having been able to use the multi axle system is that Axis 5 was the Global Assessment of Functioning. And if you said that the person had a global assessment of functioning of fifty-five or less, than the insurance companies would pretty much, not always, but usually, give us weekly sessions.
Now what we need to do is, we need to rate the severity of each diagnosis, and the good news about that, is that we get to be more specific. So, some diagnoses are rated in the DSM, they already come rated like major depression. Major Depressive Disorder comes rated, but other ones don't. You, on your documentation want to rate it: mild, moderate, severe, extreme. And extreme would be something like the person needs a day program or has just come out of the hospital, something like that.
The other thing that you want to do is note a person's barriers to treatment. And this was Axis 4. These are the bio-psycho-social stressors. And you can find a lot of these codes in the DSM 5 as T and Z codes. They are not billable. However, insurance companies are recognizing how important they are, what an influence they are in a person's ability to engage in therapy, and to make progress. So, bio-psycho-social stressors actually strengthen your case for continued treatment. And you document those in your treatment plan.
The other thing you want to do is use an assessment scale, which you are supposed to administer every three to six months. And one really good example of an assessment measure, and there are lots of them. There are quite a few free ones. But here's one you can get access to online very simply. It's the Schwartz Outcome Scale. It's a 10-measure scale and it's very quick and easy to administer. It is a basic measure for quality of life. I hope I've answered that question well enough.
Wayne
How often do you use the assessment scales besides the intake?
Beth
Every three to six months.
Wayne
That's great. So, another question, when you came to speak at my CBT consultation group meeting, you'd help us understand how thorough documentation needs to be. But maybe you could tell our audience, what are most clinicians missing in their documentation that could get them into trouble?
Beth
Well, one of the things that clinicians are missing is documenting whether the client has allergies or not. I don't know, I have not been able to find out why we need to include that, but I know that we must include it. And if we don't, we will get penalized for it.
On the treatment plan, we need to have the diagnostic criteria. We need to have the barriers to treatment, goals, the objectives, interventions. We need to list medications with dosages. A lot of clinicians don't understand that. Medications need to be listed on the treatment plan as well as progress. And you want to document progress even if it's really, really minor. Otherwise, insurance companies can come back and say, well, "they're at their lowest; excuse me, their highest level of functioning, so we're going to limit the number of sessions you can have because clearly they're not going to get any better." So, you always want to document the progress. Unless they're having a relapse of some sort.
And you want to document the duration of treatment. I know that it can be very difficult to anticipate how long a person's going to be in treatment with you. But insurance companies want to know that you're not being paid to be a best friend. So give it your best guess. Three to six months, six to nine months, nine to 12 months, twelve to 18, 18 to 24. You know, if you've got a really serious and significant PTSD case, you're going to be seeing that person for at least two years. You know, if it's chronic PTSD, so give it your best guess and have your clinical justification for it.
The thing that you need on session notes, is you need the actual start and stop time of the session, and that is for legal reasons. You also need the date of the next session, which is again, for legal reasons. If you don't have the date of the next session documented, even if you have it in your date book, you cannot prove that that person had a session for that next week. And if that person is a no show, you cannot technically bill them for that session.
Wayne
Well. Wow.
Beth
In your session, they have a session for the following week or two weeks or whatever it is, and you need to have it in your session note. You need to always have a mini mental status exam and the risk factors. And again, you need to document meds and that you've checked meds on your session. So that's a lot.
Wayne
Yeah. I mean, we quickly showed the format of the forms that you offer here. Obviously, it's very detailed these are forms that you sell as a package. Case consult note is another one that you include, that you show people.
Beth
Yeah. Even when I get a consultation on one of my own cases; I'm in a consultation group, I take a consult note with me and I write a few things down on it so that I can document it, particularly if it's a complicated case. I want to have a record of it just in case. This is something that you can use when you go to an IEP meeting or a Department of Social Services meeting.
Wayne
Yeah. So that you have a lot of....
Beth
These are very, very useful notes.
Wayne
Exactly. So, you have a lot of experience with insurance companies, working with insurance companies. Are you finding that there are any diagnoses that are now not covered by insurance companies?
Beth
Insurance companies will cover many of the diagnoses. This is a little complicated. They covered just about all the diagnoses. Just about. But there can be limits on them. So, for instance, Adjustment Disorder is time limited. So if it goes on more than six months, it either has to be something that is chronic, or what the person is adjusting to keeps changing, or you need to re-diagnose the person. So if it's Adjustment Disorder with Anxiety, perhaps the person should now be diagnosed with Generalized Anxiety Disorder.
The Unspecified diagnoses: insurance companies don't like to pay for them over a long period of time because they're not a real diagnosis, because people don't meet criteria for a specific mental disorder. It doesn't name a medical condition. So if you have something unspecified, you want to think pretty hard as to whether you can specify it. And if not, then you're going to have to justify it. You'll probably wind up with a phone review and you'll have to justify it.
Insurance companies usually will authorize for biweekly sessions if they don't authorize weekly sessions. When a client really needs weekly sessions, you want to make sure that you've got all your ducks in a row. That you're documenting everything that you can.
Wayne
Yeah, I've heard mixed messages on this, but the clinicians need to use electronic health record? Now, is that mandated or is it imminent? What's the... ?
Beth
Well, you're getting mixed messages because there's mixed messages. It was supposed to be, I believe... Now it's being pushed back to 2018. Agencies and big organization need to be on it. But private practice therapists are going to have more time to be on an EHR. And even that has been questioned as to whether we really need to be one or not. For the time being, you can still use paper records, or you can keep your notes in your computer as long as your computer or your flash drive are encrypted. I keep mine on an unencrypted flash drive and I write them the word documents on my templates. And I am actually working with a company right now to get my forms put on an EHR. But we don't need it yet and I wouldn't go out and do it right away. I mean, unless you have done it already, because I believe the requirements are in the process of changing.
Wayne
OK, so Beth, tell us specifically how you can help people with documentation. What do you do? What kind of service do you offer?
Beth
Well, first, I want to say for some people who are listening, this is enough. You got just enough information that you feel comfortable and confident that either you are doing it right or you know what to add to make sure that your covering... That you're crossing all your T's and dotting all your I's.
But how I can help people is either through group training or individual consultations.
You can also buy my forms and my templates. You get a diagnostic summary, treatment plan, and a session note, a case and collateral contact note. There's a discharge summary. There are examples. There's a case example for each one of these forms. I've included a mini mental status exam. There is an extensive list of barriers to treatment or the bio-psycho-social stressors. I'm in the process of developing a list of free assessment tools and how to get them. And the one that I just recently added, a form letter as a template to communicate with the PCP and the prescriber, which we are supposed to be doing every few months to update them. And this requirement will be more and more enforced with the implementation of the accountable care organizations. So assessment tools, we're gonna need them. And the form letters that we are communicating with the client PCPs and the prescribers.
So like I said, I provide day long trainings either in my office in Boston, or on site, at someone else's office, wherever they want me. I've done in-service trainings, presented at conferences. I've been asked back to several conferences multiple times. I do private consultations. I also review the documentation for clinics to make sure they're being compliant. So there's a lot of ways to take advantage of what I do.
I was going to say I don't know why I love doing this, but I do know why I love doing this. I love doing this because:
- I get to meet just incredible therapists. And I feel very honored and privileged to do that. And
- because I'm supporting them in doing better work and in making sure that they are there compliant with the standards of our profession.
Wayne
OK.
Beth
Wayne, thank you so much.
Wayne
Oh, thank you. We want to open it up for questions?
Beth
Thank you, everybody. Yes, please.
Wayne
Does anybody have a question for Beth? I just want to see if we can go on mute. Somebody asked for the name of the Schwartz scale again.
Beth
The Schwartz Outcome Scale S C H W A R T Z. It's online. It's free.
Wayne
David G. also asked, did she say allergies need to be listed?
Beth
Yes.
Wayne
OK, very good.
Beth
Are there any other assessments that I recommend? I can't think of them off the top of my head. I'm sorry. I would give you a few more if I could, but I can't think of them off the top of my head. Like I said, I'm in the process of putting together a whole document of those that will be available with my forms and templates.
Wayne
Here's another question. Can you provide a list of all the requirements noted in your talk?
Beth
That's part of what I train.
Wayne
OK.
Beth
I saw a question up there about can I recommend an EHR? I don't use one at this point. I can tell you that some EHRs let you create a treatment plan by clicking on a diagnosis, which will bring up the diagnostic criteria that you click on, which will bring up the intervention that you click on, which will bring up the objective that you can click on. And insurance companies generally don't like those because they're boilerplate and they recognize that the clinician really isn't thinking.
What I provide is an outline with all the cues so that you are writing exactly what you do. There are some treatment planning books that are very useful to help you kind of recognize that what you're doing really is therapy, but I don't recommend using them as your your daily go to source. And in terms of an EHR; there's Therascribe, and Therapy Notes. There are quite a few of them. I can't tell you which one I would recommend. Plus, I don't use them. I use my own.
Wayne
All right. Well, thank you, Beth. Any other questions?
Before we end, I just want to give people my name and phone number here. If you're interested in setting up your own webinar like this. We had a huge response initially. The first go around. We had eighty-seven people that signed up. This time we had close to 20. So, I think that the Linked In Group, we have twenty eight thousand people in that group. That's a pretty huge audience to draw from. So, if anybody's interested in setting up their own webinar, my contact information is on the screen here. Wayne Kessler 781-956-9999. Otherwise, thank you very much, Beth. We appreciate you taking the time to help the audience here.
Beth
I'm really glad to do it. Really, really glad to do it. And thank you. And you were terrific to work with and I really appreciate it. So, anybody who wants to run a webinar, Wayne, is really, really good. Thank you, everybody. And please feel free to be in contact with me.
Wayne
All right. Thank you, folks. Take care, Beth.
Beth
Bye-bye.
Wayne
Bye now.