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?
Mental Health Documentation for Workman’s Compensation
Mental Health Documentation for Workman’s Compensation A therapist recently asked me how to document for a Workman’s Compensation claim. Some companies will accept a summary of treatment. Most will want the client’s full record. That will include the Diagnostic Assessment, … [Read more...] about Mental Health Documentation for Workman’s Compensation
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. … [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)
Should I Use a Treatment Planning Book?
Should I Use a Treatment Planning Book? Like many answers to questions about mental health, the answer to this common question on whether or not you should use a treatment planning book is a bit more complicated than a simple yes or no. When discussing treatment plans during my trainings, I … [Read more...] about Should I Use a Treatment Planning Book?
I’d Rather Clean the Toilet than Write Progress Notes: Making Peace With An Essential Task
I’d Rather Clean the Toilet than Write Progress Notes: Making Peace With An Essential Task Q: I love being a therapist, but I hate writing progress notes and sometimes can’t bring myself to do it. I know it’s risky not to write them. Is there a way to make this task less onerous? A: Every … [Read more...] about I’d Rather Clean the Toilet than Write Progress Notes: Making Peace With An Essential Task
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