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
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?
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 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 unprepared. QUESTION … [Read more...] about Questions & Answers: Audits
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
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
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
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 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