Documentation Wizard, LLC

Documenting Medical Necessity for Psychotherapists

Essential Admin Forms for Therapists: Stay Legal, Ethical, and Protected

Private practice therapists juggle multiple roles - clinician, business owner, and administrator. But just like progress notes and treatment plans, running a private practice wasn’t taught in grad school. From clinical to legal and ethical issues to marketing and billing, the workload can be … [Read more...] about Essential Admin Forms for Therapists: Stay Legal, Ethical, and Protected

BODY-DOUBLING: Why it Helps Psychotherapists Get Progress Notes DONE!

Why Body-Doubling Helps Psychotherapists Get Progress Notes DONE!“Exhausting, annoying, demoralizing, and lonely.” This is a common refrain I hear from psychotherapists about documentation. These normal feelings breed avoidance, which leads to falling behind on notes. Behind long enough, it’s easy … [Read more...] about BODY-DOUBLING: Why it Helps Psychotherapists Get Progress Notes DONE!

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

How to Opt-Out of Medicare and Still Get Paid

Your Guide to Opting Out of Medicare as a Mental Health Provider: and How Medicare Clients Can Get ReimbursedYes, it is possible to see a Medicare client, get your full fee, and for the client to not have to pay for your service. The process isn’t even that difficult. Unlike most things … [Read more...] about How to Opt-Out of Medicare and Still Get Paid

Can You Combine the Intake Summary and the Diagnostic Session Note?

QUESTION: Can You Combine the Intake Summary and the Diagnostic Session Note?My EHR combines the Intake Summary and the Diagnostic Session Note and calls it the Intake Session Note.  What do you think of combining them?ANSWERI prefer the documents to be separated, but there is no one right … [Read more...] about Can You Combine the Intake Summary and the Diagnostic Session Note?

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?

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

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

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?

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

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

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?