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Documenting Medical Necessity for Psychotherapists

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My Blog

tele-mental health - providing therapy from home

March 28, 2020

How to Document for Tele-Mental Health During the Covid-19 Pandemic

Adjusting to Telehealth We’re all trying to adjust to a new way of living and providing mental health services. I’m going to help you navigate the needs for tele-mental health documentation during the Corona virus pandemic. Most insurance companies are now finally on board with offering … [Read more...] about How to Document for Tele-Mental Health During the Covid-19 Pandemic

Clinical Documentation,  Documenting Medical Necessity,  Golden Thread,  Passing Audits,  Progress Notes,  Psychotherapist Notes,  Session Notes,  tele-mental health,  Telehealth,  Treatment Plan,  Treatment Plans

mental health providers should charge for phone calls

February 27, 2020

Can Mental Health Providers Charge For Phone Calls?

Like most answers I give regarding being a mental health therapist and having a private practice, “yes” and “no.” WHY SHOULD MENTAL HEALTH PROFESSIONALS CHARGE FOR PHONE CALLS? Phone calls can take a lot of time and time is what we’re paid for. If you don’t charge for these phone calls, … [Read more...] about Can Mental Health Providers Charge For Phone Calls?

Case Consultation,  Clinical Documentation,  Collateral Consultation,  Documenting Medical Necessity,  Psychotherapist Notes

Writing discharge summaries

January 27, 2020

Are Discharge Summaries Mandatory?

Do you need to write a discharge summary as a mental health provider? Yes and no. Confusing? Definitely. That’s because the standards are not consistent from one insurance company to the next. Here’s what I can tell you: Discharge Summaries for Medicaid  Medicaid requires … [Read more...] about Are Discharge Summaries Mandatory?

Clinical Documentation,  Discharge Summary,  Documenting Medical Necessity,  Session Notes

women reviwing electronic medical record

November 8, 2019

EMRs and EHRs and Online Programs, oh my!

Do psychotherapists need to use EMRs or EHRs for writing clinical notes? The short answer is, “no.”  Not yet. And maybe-not-ever. There are other (better) tools psychotherapists can use for writing clinical notes and documenting medical necessity. Really? Yes! To understand the … [Read more...] about EMRs and EHRs and Online Programs, oh my!

Documenting Medical Necessity,  EHR,  EMR,  Paper Notes,  Progress Notes,  Psychotherapist Notes audits

Get higher reimbursement rates with hand drawing an upward arrow

June 23, 2019

Documenting Mental Health CPT Code 90837

Many therapists provide a 60 minute session but afraid of triggering an audit, they do not bill for it. We love our work but unless we are independently wealthy, we need to be paid to do it. We don’t get paid for providing psychotherapy. We get paid for our time. Psychotherapy is what we spend our … [Read more...] about Documenting Mental Health CPT Code 90837

Clinical Documentation,  CPT code 90837,  CPT Codes,  Documenting Medical Necessity,  Passing Audits,  Psychotherapist Notes,  Session Notes

writing psychotherapy notes

June 13, 2019

“I Love Writing Psychotherapy Notes”

If you ... experience doing your notes as a never-ending and tedious task, find it clinically irrelevant, andwould rather clean the bathroom I get it! You... don't know what or how much to write.resent the time it takes.wonder how to maintain client confidentiality.worry about legal … [Read more...] about “I Love Writing Psychotherapy Notes”

Clinical Documentation,  Documenting Medical Necessity,  Passing Audits,  Psychotherapist Notes audits,  golden thread,  progress notes

documenting low self-esteemwith young women looking into a broken mirror

December 4, 2018

How to Document “Low Self-Esteem”

Esther Perel's definition of self-esteem is, "Seeing yourself as a flawed person, and still holding yourself in high regard." It's a common occurrence that clients come to treatment feeling broken and hopeless, reporting low self-esteem, and not believing they will ever be able to hold themselves … [Read more...] about How to Document “Low Self-Esteem”

Clinical Documentation,  Documenting Medical Necessity,  documenting self-esteem,  Passing Audits,  Psychotherapist Notes,  Self-esteem

Take insurance question

September 20, 2017

I Don’t Take Insurance. Do I Still Need to Write Treatment Plans and Progress Notes?

Yes!  Documentation has always been a standard in our profession so it's required.  And here are other good reasons why. Even if you do not take insurance, if you see a client who has out-of-network benefits and uses a PPO, you can still be audited. This means you still have to justify medical … [Read more...] about I Don’t Take Insurance. Do I Still Need to Write Treatment Plans and Progress Notes?

Documenting Medical Necessity,  Private Pay,  Progress Notes,  Psychotherapist Notes,  Session Notes,  Treatment Plans progress notes,  treatment plans

SSI and SSDI Input for Disabilty

June 29, 2016

When a Client Wants SSI or SSDI

A therapist recently asked me how to handle a request from the Social Security Administration for the medical records of a client she hadn’t seen in several months and only for two sessions.  The request was accompanied by a signed release so it was legitimate. Not having access to the client’s … [Read more...] about When a Client Wants SSI or SSDI

Documenting Medical Necessity

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