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Documenting Medical Necessity for Psychotherapists

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My Blog

clinical mental health documentation workman's comp

March 23, 2023

Mental Health Documentation for Worker’s Compensation

Mental Health Documentation for Worker’s CompensationA therapist recently asked me how to document for a Worker’s Compensation claim. Some companies will accept a summary of treatment.  Most will want the client’s full record.  That will include the Diagnostic Assessment, Treatment Plan, … [Read more...] about Mental Health Documentation for Worker’s Compensation

Documenting Medical Necessity,  Progress Notes,  Psychotherapist Notes clinical documentation,  clinical documentation specialist,  mental health documentation,  progress notes,  psychotherapist,  psychotherapy,  therapy,  workman's comp,  workman's compensation

Documentation Wizard mental health clinical documentation expert

February 15, 2023

5 Types of Insurance Reviews

If you’ve ever gotten a letter from a health insurance company and felt your blood pressure spike while you open it, you’re not alone. The fear of being audited can cause as much anxiety as having a suicidal client.  But just like a range in client risk, there is more or less risk involved with … [Read more...] about 5 Types of Insurance Reviews

Clinical Documentation,  Psychotherapist Notes audit,  audits,  clinical documentation,  clinical documentation specialist,  progress notes,  psychotherapist,  psychotherapy,  therapist,  therapy

mental health documentation insurance audit appeal

January 24, 2023

Winning an Insurance Audit Appeal!

I WON an Overpayment Recoupment for mental health services from Blue Cross Blue Shield! And I’m sharing what I did in case you find yourself dealing with the same thing.I got the dreaded insurance recoupment letter from BCBS saying they overpaid me (over $1700) and demanded their money back. They … [Read more...] about Winning an Insurance Audit Appeal!

Clinical Documentation audit,  audits,  clinical documentation,  clinical documentation specialist,  psychotherapist,  psychotherapy,  therapist,  therapy

different forms for documentation as viewed by a therapist

December 30, 2022

What Makes Documentation Wizard Forms Different? (From All Other Forms)

Remember being a teenager at a high school dance?  You wanted to cut the rug, but you didn’t know how because you were never taught.  If you intuitively knew how to “just dance,” you were golden. Otherwise, you may have either flailed around imitating your friends, or hid in the corner … [Read more...] about What Makes Documentation Wizard Forms Different? (From All Other Forms)

Clinical Documentation clinical documentation,  clinical documentation specialist,  progress notes,  psychotherapist,  psychotherapy

Simple Practice Interview

November 15, 2022

Overview of Creating and Integrating Forms into Simple Practice

[Beth Rontal ] Welcome everyone for my first live Facebook. So we're very happy to have you here. I am Beth Rontal, the Documentation Wizard and LICSW. And I am welcoming Frances Harvey from My Solution Services. And we're gonna give an overview of how to customize, create, and integrate your … [Read more...] about Overview of Creating and Integrating Forms into Simple Practice

Documenting Medical Necessity

Alert!!

August 10, 2022

ALERT — CareDash and BetterHelp

Watch Your BackIf you are a therapist, social worker, counselor, or psychologist, I’d like to call your attention to the fraudulent and unethical business practice of a company called CareDash.CareDash has created a directory of 1000s of therapists and your name might be on it. This may sound like … [Read more...] about ALERT — CareDash and BetterHelp

Clinical Documentation,  Fasle business practice counselor,  psychologist,  psychotherapist,  psychotherapy,  social worker,  therapy

mental health documentation tx planning books

July 8, 2022

Should I Use a Treatment Planning Book?

Should I Use a Treatment Planning Book?Like many answers to questions about mental health, the answer to this common question on whether or not you should use a treatment planning book is a bit more complicated than a simple yes or no.When discussing treatment plans during my trainings, I often … [Read more...] about Should I Use a Treatment Planning Book?

Treatment Plan,  Treatment Plans clinical documentation,  clinical documentation specialist,  psychotherapist,  psychotherapy,  therapy,  treatment planning,  treatment planning book,  tx planning,  tx planning book

insurance audit therapist

June 6, 2022

Questions & Answers: Audits

Questions & Answers: AuditsTherapists aren’t taught clinical documentation in school, leaving them vulnerable to audits and claw backs. The Documentation Wizard is here to help answer some of the most commonly asked questions about audits so you aren’t caught unprepared.  QUESTION 1: … [Read more...] about Questions & Answers: Audits

Session Notes

how to write tx plans insurance audit therapy notes

February 3, 2022

Questions & Answers: Treatment Plans

Questions & Answers: Treatment PlansTrying to figure out everything you need to know about clinical documentation can make your head spin! The good news is, I’m here to help! In this month’s blog post I answer some of the most commonly asked questions about treatment plans.QUESTION 1: Primary, … [Read more...] about Questions & Answers: Treatment Plans

Session Notes

No Surprise Act

January 10, 2022

No Surprise Act May Be a Surprise

No Surprises Act May Be a SurpriseHappy New Year! I hope you had a wonderful holiday celebration and got some time to relax and recharge. Because change is here. Effective January 1, 2022, the new NO SURPRISE ACT (NSA) is an unwelcome surprise for many therapists!Very briefly, the primary goal of … [Read more...] about No Surprise Act May Be a Surprise

Clinical Documentation No Surprise Act,  NSA

Taking Progress Notes

September 18, 2021

I’d Rather Clean the Toilet than Write Progress Notes: Making Peace With An Essential Task

Q: I love being a therapist, but I hate writing progress notes and sometimes can’t bring myself to do it. I know it’s risky not to write them. Is there a way to make this task less onerous?A: Every therapist knows that avoiding progress notes puts their practice in jeopardy. But of the thousands of … [Read more...] about I’d Rather Clean the Toilet than Write Progress Notes: Making Peace With An Essential Task

Documenting Medical Necessity audits,  clinical documentation,  clinical documentation specialist,  progress notes,  psychotherapist

how to document prognosis for mental health

July 13, 2021

How to Document Prognosis for Mental Health

Medicare just added Prognosis to its list of documentation requirements. UGH! One more thing to think about and document. But how?What Is a Prognosis?Prognosis refers to making an educated guess about the expected outcome of treatment. Based on the medical model, it’s a prediction of a client’s … [Read more...] about How to Document Prognosis for Mental Health

Session Notes audit,  clinical documentation,  clinical documentation specialist,  counseling,  diagnosis,  health insurance audit,  medicare,  mental health,  mental health care,  mental health therapist,  prognosis,  psychotherapist,  psychotherapy,  therapist,  therapy

how to survive a health insurance audit for psychotherapists

May 7, 2021

How To Survive A Health Insurance Audit

The Insurance Vultures are CirclingInsurance companies have recently been conducting audits, like vultures looking for dinner. Especially Medicare.Fight, flight, freeze, or fawn! An audit letter from a health insurance company is enough to send shock waves through your body and make your mind go … [Read more...] about How To Survive A Health Insurance Audit

Session Notes audit,  counseling,  health insurance,  health insurance audit,  medicare,  psychotherapist,  psychotherapy,  psychotherapy notes,  therapist,  therapy

clinical documentation specialist psychotherapy adjustment disorder

December 2, 2020

Can Adjustment Disorder be Billed for Longer Than 6 Months?

Is it possible to bill insurance for someone who has Adjustment Disorder for longer than 6 months? Will this be a red flag and trigger an audit? As is typical, when it comes to answers for psychotherapy – maybe and maybe not. To understand the answer to this question, it’s necessary to know the … [Read more...] about Can Adjustment Disorder be Billed for Longer Than 6 Months?

Session Notes adjustment disorder,  clinical documentation,  clinical documentation specialist,  documentation,  documentation specialist,  insurance,  psychotherapist,  psychotherapy,  therapy

Documenting Safety Protocols

October 19, 2020

Documenting Safety Protocols for Face-to-Face Psychotherapy Sessions

Documenting Safety Protocols for Face-to-Face Psychotherapy SessionsMost people agree – change creates upset. Despite the restrictions we experience due to the Covid-19 pandemic, change seems constant. This pandemic will not let us rest in what we already know. Every week or so, there’s something … [Read more...] about Documenting Safety Protocols for Face-to-Face Psychotherapy Sessions

Covid-19,  Documenting for Covid-19 Pandemic,  Pandemic,  Session Notes

Reopening your psycholtherapist office

July 22, 2020

Helpful Guidelines to Reopening your Psychotherapist Office during the COVID-19 Pandemic

During the COVID-19 pandemic, we have all made changes and adjustments in our practices to safely meet the needs of our patients and continue to stay safe ourselves. Since many states are gradually relaxing their stay at home orders, you may find some or all of your clients desiring in-person … [Read more...] about Helpful Guidelines to Reopening your Psychotherapist Office during the COVID-19 Pandemic

Covid-19,  Documenting for Covid-19 Pandemic,  Pandemic informed consent,  mental health and covid-19,  psychotherapy and covid-19,  reopening psychotherapy offices

why therapists need to be anti-racist

July 21, 2020

Why Therapists Need to Be Anti-Racist

Documentation Wizard stands in solidarity with those who are opposed to the senseless violence and oppression of Black people in this country. As I witness the horrors of what is happening, I see how it is increasing people's sense of alienation, hopelessness, and helplessness. The 21st century … [Read more...] about Why Therapists Need to Be Anti-Racist

Psychotherapist Notes

documenting treatment changes during covid-19

April 9, 2020

How to Document Changes in Treatment During Covid-19 Without Writing Another Plan

Private practice therapists are expected to write a new treatment plan once a year. What happens when your well thought out plan gets thrown to the wind before it's time for an update? This scenario may be happening right now since the sudden outbreak of the Covid-19 pandemic. Problems, goals, and … [Read more...] about How to Document Changes in Treatment During Covid-19 Without Writing Another Plan

Clinical Documentation,  Covid-19,  Documenting for Covid-19 Pandemic,  Documenting Medical Necessity,  Pandemic,  Psychotherapist Notes,  Session Notes,  Treatment Plans

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