Beth Rontal, LICSW, a private practice therapist and the Documentation Wizard® is a nationally recognized consultant on mental health documentation. Her Misery and Mastery® trainings and accompanying forms are developed to meet strict Medicare requirements. … [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 … [Read more...] about BODY-DOUBLING: Why it Helps Psychotherapists Get Progress Notes DONE!
Mental Health Documentation and Selfcare
Why in the world would anybody put “selfcare” and “documentation” in the same sentence? Because when therapists start feeling overwhelmed and burnt out the very first thing that’s sacrificed are progress notes! Then the inner Critic berates you by saying, “you’re a bad therapist because you’re … [Read more...] about Mental Health Documentation and Selfcare
7 Documentation Requirements You Can Apply Right Now
7 Documentation Requirements You Can Apply Right Now Here are some common questions and answers when it comes to mental health documentation requirements. 1. Question: Are notes for private pay clients the same as for insurance? Answer: Yes – justifying medical necessity has become the … [Read more...] about 7 Documentation Requirements You Can Apply Right Now
Challenges with AI in Progress Notes
Insights into using AI from a Mental Health Therapist and Documentation Expert In 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 Reimbursed Yes, 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
Timely Progress Note Completion in Mental Health Documentation
The most frequently asked question I get in my documentation course is, “What is the deadline for progress note completion? This is a frustrating question because like so many aspects of mental health, there is no definitive answer. Understanding the Confusion Our professional codes of … [Read more...] about Timely Progress Note Completion in Mental Health Documentation
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? ANSWER I prefer the documents to be separated, but there is no … [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, … [Read more...] about Should I Document Medications on Progress Notes?
Questions & Answers: Audits
Questions & Answers: Audits Therapists 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 … [Read more...] about Questions & Answers: Audits
Questions & Answers: Treatment Plans
Questions & Answers: Treatment Plans Trying 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 … [Read more...] about Questions & Answers: Treatment Plans
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 … [Read more...] about How to Document Prognosis for Mental Health
How To Survive A Health Insurance Audit
The Insurance Vultures are Circling Insurance 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 … [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 … [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 Sessions Most 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 … [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 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
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?