Misery or Mastery
Documenting Medical Necessity
- Reduce Anxiety
- Maintain Professional Integrity
- Protect Income
VIDEO COURSE NAME
Misery or Mastery TM: Documenting Medical Necessity for Psychotherapists
This series of 5 videos to which you have unlimited online access.
The series comes with:
- a time-stamped and indexed transcript to find the exact subject you may be looking for on the recording.
- 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.
- access to a private Face Book group called, Misery or Mastery: Documenting Medical Necessity for Psychotherapists.
All sales are final.
CONTINUING EDUCATION HOURS: 4.5
CEs are available for: Psychologists, Social Workers, Marriage and Family Therapists, Licensed Mental Health Counselors. For state by state approval by profession, please click here.
Please note that it is the responsibility of the licensee to check with their individual state board to verify CE requirements for their state.
CE COST: $9.99
Clinical Documentation has always been integral to the professional standard of care. Yet many psychotherapists are unsure how to document the good work they provide. As a result, they can feel at the mercy of insurance companies, spending an enormous amount of time justifying treatment, fighting rejected insurance claims, fearing or preparing for audits, writing disability reports and losing income. Clinicians both in private practice and those working in agencies and group practices, as well as clinic owners and managers report there is little guidance about what to write while clinicians find that there is little time to write it. Paperwork often seems unrelated to being helpful to the client. Confusion over third-party expectations and often substandard paperwork is a common result, leaving both clinician and clinic vulnerable to a financial loss if records are audited, or to legal, ethical or professional issues if records are subpoenaed.
With the growing concerns about addiction, child safety, family violence, legal issues, and the corresponding rise in oversight, whether from insurance companies, the department of social services, workman’s compensation, or the courts, the more important good record keeping has become. Additionally, because the courts can mandate access to records, understanding issues of confidentiality and privacy in relationship to documentation requirements are critical.
Good documentation skills should help organize clinical thinking. Progress notes, treatment plans, case and collateral contact notes, discharge and diagnostic summaries should be able to be done quickly and efficiently and provide a vehicle for formulating and reflecting on high quality clinical work rather than being a detour or afterthought. Good documentation supports good clinical practice, facilitates getting authorizations, and helps mental health professionals and clinics pass insurance audits, thus saving thousands of dollars in potential recoupments and lost productivity. It contributes to a marked reduction in work related anxiety and increased job satisfaction.
Since psychotherapy is covered by medical insurance, the gold standard for documentation is now based on the need to satisfy insurance company requirements. The most rigorous standards for clinical documentation are Federal, which is why most third-party payors base their requirements on Medicare standards.
That standard is conceptualized as “medical necessity.” A fundamental feature of medical necessity is, the “Golden Thread.” When the Golden Thread is employed, each element of the therapeutic process is clearly documented so that the connection between all aspects of clinical work flows logically from one record to the other. In-other-words, the criteria for a client needing services and the Golden Thread work together to justify medical necessity. At the same time, it is important that the clinician’s voice be heard in a narrative so that it is clear how they conceptualize the treatment rather than relying solely on a template with boiler plate drop down menus for all aspects of the record. This includes effectively documenting clinical progress while maintaining confidentiality. When clinical documentation is operationalized using this effective, efficient, and distinct procedure, medical records are clear, compliant and clinically useful. Documentation is necessary even for those psychotherapists who do not take insurance but still wish to meet professional, legal and ethical standards.
Applying the Documentation Wizard TM process to whatever system is used, increases accuracy and efficiency. It simultaneously reduces anxiety and resistance and contributes to quality care. The concepts and practice of this system are taught to Medicare standards and have a proven track record of success. Implementation of this system helps pass stringent Medicare audits, potentially saving clinics and clinicians thousands of dollars. Additionally, a reduction of time spent writing and rewriting paperwork, coupled with a significant increase in productivity and profits can lead to greater job satisfaction and less burnout. Choose mastery over misery and allow good clinical documentation to be a contribution to high quality care rather and protect your practice at the same time.
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.
Unlimited access to a series of 5 videos.
Introduction (35 min: 31 sec.)
- 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” and how it relates 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
Part 1: How to Write a Treatment Plan (1 hour: 44 min.)
- Definition of a treatment plan
- Everything that’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
- How to describe the diagnostic criteria using behavioral language
- Questions to ask
- Creating a clear connection between the problem, goals, objectives, and interventions
- Protecting client and therapist with a risk assessment
- Evaluating and documenting progress
- Frequency of treatment plans
- How to avoid making yourself crazy writing your treatment plans
Practice writing a treatment plan with review
Part 2: How to Write a Session Note (43 min: 30 secs)
- Definition of a session note and how it relates to the treatment plan
- Everything that’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
- Maintaining client confidentiality
- Justifying multiple sessions
- How to document changes in treatment plan in the session note
Practice writing a session note and review
Part 3: How to Write Case/Collateral Contact Note, Discharge Summary, & Diagnostic Summary (28 min: 8 sec)
- How to Write a 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
- How to write a case/collateral Contact Note that maintains the “golden thread” and justifies medical necessity with case examples
- Clinical and legal Importance of Case/Collateral Contact Note
- How to Write a Discharge Summary
- 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
- To send a termination letter or not
- How to Write an Intake or Diagnostic Summary
- Establishing the connection between the diagnosis and treatment
- How to write a diagnostic summary that lays the ground for medical necessity and initiates the Golden Thread
- What’s needed in a diagnostic summary and why
- Legal requirements of a diagnostic summary
- When to write a diagnostic summary
Part 4: Red Flags, Wrap-up (29 min: 41 sec)
- What triggers an audit
- How to fail an audit
- Examples of documentation mistakes that can be seen as insurance fraud
- Are paper notes OK? To EHR or not?
- Basic Do’s and Don’ts
- What’s next
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 facility therapists, mental health counselors, creative arts therapists, addictions professionals, and other interested human service staff.
Beginning, Intermediate, Advanced
Continuing education credit is available through Commonwealth Educational Seminars for psychologists, social workers, marriage and family therapists, mental health counselors.
Please note that it is the responsibility of the licensee to check with their individual state board to verify CE requirements for their state. Please click here to see all states that are covered for your licensure by Commonwealth Educational Seminars.
A post-test is necessary to obtain your CEs. Psychologists, Social Workers, Marriage and Family Therapists, and Mental Health Counselors: once you complete the evaluation, you will receive Certificate Download Instructions, which will show you how to download your certificate.
Commonwealth Educational Seminars (CES) seeks to ensure equitable treatment of every person and to make every attempt to resolve grievances in a fair manner. Please submit a written grievance to Beth Rontal, email@example.com, and 617-522-6611. Grievances will receive, to the best of our ability, corrective action in order to prevent further problems.
This video comes with a transcript for the hearing impaired.
|POWERPOINT||AUDIO PACKAGE||VIDEO PACKAGE|
|Detailed Power Point Manual with case examples||Audio of complete training||Video of complete training|
|(Does not include practice demo video)||Contains demo in audio format (1)||Contains embedded demo video (1)|
|(Does not include Practice Forms)||Demo Practice Forms (2)||Demo Practice Forms (2)|
|Indexed and Time-stamped Transcript (3)||Indexed and Time-stamped Transcript (3)|
|Detailed Powerpoint Manual with case examples||Detailed Powerpoint Manual with case examples|
|Membership in private Facebook Group (4)|
|Discount on all Misery or Mastery(TM) Documentation Forms (5)|
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.
3 This detailed indexed and time-stamped transcript helps you to easily find a topic to review.
4 The Private Facebook Group is created for therapists who have been through the Misery or Mastery TM training. Get the help you need, share struggles, successes, practice your skills and share resources.
5 Three different packages that prompts you to follow the Golden Thread, cross your T’s and dot your I’s.