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Documenting Medical Necessity for Psychotherapists

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medical necessity

mental health clinical documentation - Documentation Wizard, Beth Rontal, LICSW

May 16, 2024

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

Passing Audits compliance,  medical necessity,  medicare,  requirements

Intake Summary - Beth Rontal, LICSW, Documentation Wizard - mental health psychotherapy documentation

March 1, 2024

Question & Answer: Intake Summary

Question & Answer: How do I write an Intake Summary without violating client confidentiality? QUESTION I'm struggling with how to effectively document in a manner that satisfies "medical necessity" requirements while also protecting the privacy of my clients. I understand how to keep … [Read more...] about Question & Answer: Intake Summary

Documenting Mental Health confidentiality,  EHR,  intake summary,  medical necessity

Timely Progress Note Completion

July 6, 2023

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

Documenting Mental Health billing,  ethics,  medical necessity,  progress notes,  timely documentation

how to survive a health insurance audit for psychotherapists

May 7, 2021

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

Passing Audits appeals,  audits,  compliance,  documentation,  insurance,  medical necessity

clinical documentation specialist psychotherapy adjustment disorder

December 2, 2020

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?

Health Insurance (including billing) adjustment disorder,  billing duration,  documentation,  DSM-5,  insurance audit,  medical necessity

Get higher reimbursement rates with hand drawing an upward arrow

June 23, 2019

Documenting Mental Health CPT Code 90837

Many therapists provide a 60 minute session but afraid of triggering an audit, they do not bill for it. We love our work but unless we are independently wealthy, we need to be paid to do it. We don’t get paid for providing psychotherapy. We get paid for our time. Psychotherapy is what we spend our … [Read more...] about Documenting Mental Health CPT Code 90837

Health Insurance (including billing) audits,  billing,  CPT 90837,  medical necessity

couples counseling

May 17, 2016

How to Diagnose for Couple’s Counseling

Many couples presenting for couple’s counseling do not fit into a billable diagnostic category. How do I write a treatment plan and session notes -- or bill the insurance company if I don’t have a diagnosis? I’ve been getting a version of this question in my workshops, Misery or Mastery; Essential … [Read more...] about How to Diagnose for Couple’s Counseling

Documenting Mental Health adjustment disorder,  couple’s counseling,  diagnosis,  documentation,  ethics,  ICD-10,  medical necessity

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