VIDEO COURSE NAME
Misery or Mastery: Documenting Medical Necessity for Psychotherapists
This series of 5 videos to which you have unlimited online access for one year.
The series comes with:
- the Powerpoint slide deck to make comments and use as reference while writing your notes.
- an audio recording of each video to listen in the car, at the gym, or even while washing the dishes.
- practice treatment and practice session note forms to be used during the video training.
- complete agenda detailing entire workshop.
All sales are final.
Beth Rontal, LICSW, is a nationally recognized and engaging speaker on clinical documentation for those working in agency behavioral health settings, as well as private practice clinicians. Her Documentation Wizard ™ training programs empower clinicians, reduce anxiety about documentation, and further professional integrity. She has created a formula that simplifies the documentation process by systematically linking effective documentation with quality care. This helps to pass audits and protect income. Beth mastered her teaching skills with thousands of hours supervising and training psychotherapists. She writes blogs on clinical documentation, co-chairs the NASW Private Practice Shared Interest Group, and has a private practice in Brookline, MA, specializing in working with people who struggle with emotional eating.
YOU WILL LEARN
- Apply the clinical documentation process for writing successful session notes, treatment plans, case consults, discharge and intake summaries.
- Demonstrate how to translate your work into the behavioral language required by insurance companies.
- Apply the “golden thread” to justify medical necessity.
- Identify Red Flags that could trigger an audit and result in an insurance recoupment.
Unlimited access to a series of 5 videos.
MODULE 1: INTRODUCTION - FUNDAMENTALS OF DOCUMENTATION (50 minutes)
- The Topic Clinicians Love to Hate.
- You’re not crazy, or stupid. You’re just not trained.
- Why document?
- Writing for different “masters.”
- Documentation through the lens of medical necessity.
- “The Golden Thread” as the key element to medical necessity.
- Documentation as a contribution to good clinical work.
- Documentation as protection of income and agent of professional integrity.
- Anxiety-reducing answers to common questions.
- Avoiding documentation fatigue.
- Why private pay therapists need to know documentation requirements.
MODULE 2: THE TREATMENT PLAN (2 hours 9 minutes)
- Avoid the cookie cutter treatment plan and write ones that are clinically useful.
- What's needed in a treatment plan and why.
- Writing a treatment plan that justifies medical necessity.
- Implementing the Golden Thread with case examples.
- The Treatment Plan Formula.
- Operationalizing the presenting problem.
o How to describe the diagnostic criteria using behavioral language.
o Questions to ask.
- Creating a clear connection between the problem, goals, objectives, and interventions.
- The distinction between goals and objectives and why it’s important.
- Protecting client and therapist with a risk assessment.
- Evaluating and documenting progress.
- How to evaluate and document prognosis .
- Frequency of treatment plans
- How to avoid making yourself crazy writing your treatment plans
Practice writing a treatment plan with review
MODULE 3: THE SESSION NOTE (1 hour 22 minutes)
- Definition of a session note and how it relates to the treatment plan.
- What's needed in a session note for insurance companies and the law, and why.
- Writing a session note that justifies medical necessity using behavioral language and the “golden thread” with case examples.
- What to include in the “clinical content” part of the note.
- Why clinical assessments are necessary and how to write them.
- Writing intervention that represent your work rather than the one-size fits-all interventions found in treatment planning books
- Determining how much or how little to write.
- Documenting risk.
- Maintaining client confidentiality.
- How to justify the use of 90837.
- Justifying multiple sessions in one week.
Practice writing a session note and review
MODULE 4: Case/Collateral Contact Note, Discharge Summary, & Diagnostic Summary (48 minutes)
Case/Collateral Contact Note
- The difference between a Case and Collateral Contact Note.
- Everything that’s needed in a Case and Collateral Contact Note and why.
- Relationship to the treatment plan.
- Maintain the “golden thread.”
- Justifies medical necessity with case examples.
- Clinical and legal Importance of Case/Collateral Contact Note.
- Definition of a discharge summary and how it relates to the treatment plan.
- Everything that’s needed in a discharge summary and why.
- How the discharge summary completes the Golden Thread.
- Legal considerations of a discharge summary.
- Termination letter or not.
Intake or Diagnostic Summary
- Establishing the connection between the diagnosis and treatment.
- Initiating the Golden Thread.
- Laying the ground for medical necessity.
- What’s needed in a diagnostic summary and why.
- What relevant history to include.
- What kind of risk to document and how.
- Legal requirements.
- Ethical requirement
- Demonstrating culturally competent treatment with a thorough risk assessment..
- When to write a diagnostic summary.
MODULE 5: RED FLAGS & LEGAL ISSUES - AND HOW TO AVOID THEM (37 minutes)
- common mistakes that will trigger an audit.
- What diagnoses can trigger an audit.
- How to fail an audit.
- What Medicare does not cover.
- Documenting “poor self-esteem.”
- Documentation mistakes that appear as insurance fraud.
- Avoiding legal nightmares.
- Documenting unusual clinical issues.
- How to choose a documentation template.
- To EHR or not? Are paper notes OK?
- And much more.
WHAT PEOPLE ARE SAYING
"Beth's documentation workshop is an unexpected gem: documentation made bearable by a group setting, clear and useful outlines, and the hidden surprise that it all improves one's thinking and thus conscious treatment of clients. I highly, highly recommend it."
- Zonda Mercer, MD.
"You are a wonderful instructor and I look forward to listening more times to this online course. you really have a wonderful teaching style and offer a great deal of pertinent information. Wish I had met you 25 years ago!"
- Jamie Elizabeth Medvene, Ph.D.
"I am delighted that I no longer feel that being an intuitive, attuned therapist trained in the Internal Family Systems Model is a barrier for accomplishing this goal! This was in large part because of Beth’s ability to teach documentation skills with confidence, curiosity, compassion and a LOT of clarity! Thank you, Beth!"
- Debbie Armstrong, LICSW
"Huge thanks for the great workshop yesterday, Beth. It was a wonderful and worthwhile program, and we very much appreciated how smooth and easy you made the whole process. I know that I personally learned a lot and found your presentation style and organization really helpful. Evaluations were overwhelmingly positive. Here are a few of the comments that stood out to me:
--Such an anxiety-reducing course!
-- Lives up to the hype!
--Very informative and great that the presenter has such in-depth knowledge of therapy."
- Barbara Burka, LICSW,
Director of Clinical Practice and Therapy Matcher for NASW MA
"I have been working on developing treatment plans along with my clients during sessions and have been finding the process extremely helpful for our work. So for me the class is improving my clinical work as well as my documentation skills."
- Barbara Kaplan, LICSW
"In January I received notice of a Medicare audit of 40 claims (for 90834). I am in Florida. I got the results today - 0% error rate and no clawback. I used Beth's forms. Just wanted to share this good news with everyone. Thank you, Beth Rontal, for simplifying the process. The auditor had nothing to say except 'keep up the good documentation.' Yay!!"
-- Linda Brant, Ph.D.
"I took your documentation course and created a session note template in my EHR based on the clinical forms I purchased from you, and guess what! EVERY. SINGLE. NOTE. done before the next session starts! Total game changer! THANK YOU!!!!! I have ALWAYS struggled with the narrative. Feels like too much or not enough. Even my previous templates that were mostly check boxes would take me too long because I felt I had to tell a story. Now that I know about using behavioral language that doesn’t tell a story, using the patient’s quote, describing my interventions, and the easy 1-2 sentence assessment, I don’t need to worry about that anymore and my documentation is a breeze! WELL WORTH THE MONEY AND WILL HIGHLY RECOMMEND!!"
-- Holly S, LCSW-R, New York
There are a variety of reputable websites regarding best practice standards for documenting medical necessity. A few select sites include: Association for Behavioral Health Care; Massachusetts Standardized Documentation Project http://bit.ly/2NdzDET; Medical Documentation for Behavioral Health Practitioners 2015 at https://go.cms.gov/2EkA9OV; and a specific social work resource book Sidell, Nancy L. Social Work Documentation; a Guide to Strengthening Your Case Recording, NASW Press, Washington, DC, 2011. & revised edition, 2015 http://bit.ly/2Eh5yBt
social workers, psychologists, marriage and family therapists, mental health counselors, creative arts therapists, addictions professionals, and other interested human service staff.
Beginning, Intermediate, Advanced
In support of improving patient care, this activity has been planned and implemented by Amedco LLC and Documentation Wizard (DD). Amedco LLC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Participants must attend 100% of the program to earn 6 CEs approved for eligible professions. Please click here for accreditation by profession and state. It is up to each professional to determine if they are eligible for CEs.
IT IS YOUR RESPONSIBILITY TO MAKE SURE OUR CE APPROVALS MEET THE QUALIFICATIONS OF YOUR STATE LICENSING BOARD.
ACCOMMODATIONS FOR HARD OF HEARING
This video is closed-captioned.
|VIDEO PACKAGE||Video of complete training|
|Contains embedded demo video (1)|
|Demo Practice Forms (2)|
|Detailed Powerpoint Manual with case examples|
|Discount on all Misery or Mastery(TM) Documentation Forms (3)|
This pricing is for single use only.
Group practice and site licenses available. Please inquire.
1 This Demo Video is a short mock therapy session where the therapist and client co-create a treatment plan.
2 Two Practice Forms, to practice writing a treatment plan and a session note based on the demo. These are training forms only. The Clinical Forms are not included in the purchase of the Video Package
3 Three different packages that prompts you to follow the Golden Thread, cross your T’s and dot your I’s. Includes a 15% discount on the Forms packages for up to 1 month after your purchase. This gives you plenty of time to watch the video and determine your needs. There are no additional bonuses outside of the 15% discount on the Forms pages for 1 month. You will receive an email after purchases detailing how to use your 15% discount.