Documentation Wizard, LLC

Documenting Medical Necessity for Psychotherapists

Mental Health Documentation in an Uncertain World

Ethical Considerations for Psychotherapists In today’s rapidly shifting social and political landscape, therapists are navigating new challenges when it comes to documentation. Many clinicians find themselves balancing truthful and ethical documentation with the increased need to protect client … [Read more...] about Mental Health Documentation in an Uncertain World

Medicare and Telehealth Coverage: Clearing Up the Confusion

Life before telehealth is a dim memory. You may have given up your office during the pandemic, saw all your clients virtually and now prefer to keep it that way. Or you have a hybrid practice of in-person and virtual services. So, like me, you may have panicked when you heard that Medicare providers … [Read more...] about Medicare and Telehealth Coverage: Clearing Up the Confusion

Client, Patient, or Name: Which to Use in Mental Health Documentation?

Client, Patient, or Name: Which to Use in Mental Health Documentation?“What is the proper way to refer to a client when writing my notes?  Do I use their first name, or do I refer to them as ‘client’ or ‘patient,’ which is their role in our relationship?” I get this question a lot and am fond … [Read more...] about Client, Patient, or Name: Which to Use in Mental Health Documentation?

Challenges with AI in Progress Notes

Insights into using AI from a Mental Health Therapist and Documentation ExpertIn an era where technology permeates every aspect of our lives, it's no surprise that artificial intelligence (AI) is finding a home in mental health care. One area where AI is gaining greater use is in the creation of … [Read more...] about Challenges with AI in Progress Notes

Can You Use AI for Mental Health Progress Notes?

Can You Use AI for Mental Health Progress Notes?Although AI has been around for quite a few years, it recently burst onto the scene like fireworks and is causing a lot of noise.  Some psychotherapists are already raving about how it cuts down on the time it takes to write their notes and how … [Read more...] about Can You Use AI for Mental Health Progress Notes?

Should I Document Medications on Progress Notes?

QUESTION: Should I Document Medications on Progress Notes?I have heard from others, who consider themselves Medicare documentation experts, that it is unnecessary to document anything about psychiatric medication compliance and effectiveness. They advise against it as it is the prescriber's job, not … [Read more...] about Should I Document Medications on Progress Notes?

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

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!

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)

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

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

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

Adjusting to TelehealthWe’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 tele-mental … [Read more...] about How to Document for Tele-Mental Health During the Covid-19 Pandemic

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, you are … [Read more...] about Can Mental Health Providers Charge For Phone Calls?

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 discharge summaries for … [Read more...] about Are Discharge Summaries Mandatory?

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

“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 bathroomI 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 issueslose sleep … [Read more...] about “I Love Writing Psychotherapy Notes”

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 in … [Read more...] about How to Document “Low Self-Esteem”