Medical Necessity, Insurance Requirements, & Documentation.
Although the law requires insurers to offer the same access to mental health care as to physical care, it doesn’t require them to rely on evidence-based guidelines or those endorsed by professional societies in determining medical necessity. Instead, when deciding what to pay for, the government allows insurers to set their own standards.
Insurers generally face few limitations on how they define what kind of mental health care is medically necessary. They often create their own internal standards instead of relying on ones developed by nonprofit professional medical societies. These standards can then be used to challenge diagnoses or treatment plans.
Insurers say they conduct what they call utilization reviews, in which they can request and sift through therapy progress notes full of sensitive details, to assess whether providers are delivering appropriate care. However, providers, mental health care advocates and legislators have found that these reviews are often used as pretexts by insurers looking for a reason to dispute the necessity of treatment.
In recent years, at least 24 states have passed legislation to try to regulate how insurers conduct reviews of behavioral health care.
Most of these states ask insurers to provide details on their treatment criteria or limitations, but some states appear to be violating their own laws by not posting information publicly.
Insurers generally face few limitations on how they define what kind of mental health care is medically necessary. They often create their own internal standards instead of relying on ones developed by nonprofit professional medical societies. These standards can then be used to challenge diagnoses or treatment plans.
Insurers say they conduct what they call utilization reviews, in which they can request and sift through therapy progress notes full of sensitive details, to assess whether providers are delivering appropriate care. However, providers, mental health care advocates and legislators have found that these reviews are often used as pretexts by insurers looking for a reason to dispute the necessity of treatment.
In recent years, at least 24 states have passed legislation to try to regulate how insurers conduct reviews of behavioral health care.
Most of these states ask insurers to provide details on their treatment criteria or limitations, but some states appear to be violating their own laws by not posting information publicly.
Documenting medical necessity
It is the therapist's responsibility to communicate with the insurer about how the medical necessity criteria for therapy continues to be met through therapy. Although the medical necessity for medical issues tends to be more or less straightforward with the ways we objectively measure physical illness with tests, labs, or imaging, establishing medical necessity for mental health can sometimes be more challenging to objectively measure, quantify, or "prove" in the ways insurers, auditors, or others want to see it documented. "Medical necessity" is a term that often includes a specific set of criteria that insurance companies use to determine whether they are going to pay for a service. If an insurer deems a service "medically necessary," it means they agree the service is needed and clinically agree to pay for it. However, clinical approval is not a complete guarantee of payment. This is caused by other administrative processes like coding, timeliness, network rules, etc. that could interfere with reimbursement. Insurance is fixated on improvements in the cheapest way possible. Most insurers understand the value of psychotherapy, at least in terms of a low-cost intervention to the general well-being of individuals, and especially in comparison to higher-cost services like those in a hospital setting. Insurance does not necessarily care about which evidence-based treatment you are using. It is a myth that your notes or documentation have to "look like CBT," for example. Insurers want to pay for (and see documented) the things you need a master's degree or Ph.D. to administer. Elements like empathy, active listening, reflecting, paraphrasing, support, and person-centered interventions will not be well received. The best way to navigate medical necessity is by having clear documentation from the very beginning or first session of treatment. It is extremely difficult to know the nuances of what each insurer wants to see. Medical necessity and legal documentation are broken down into a few areas:
Progress Notes
“Progress notes” — as defined by the Health Information Portability and Accountability Act (HIPAA) — are a REQUIRED part of the client’s medical record and reflect what occurred in each visit. HIPAA states they may include assessment and diagnosis, treatment modality and frequency, session start/stop times, topics discussed, interventions, medication monitoring, test results, summaries of functioning, symptoms, prognosis, and progress.
Progress Note Template Many templates automatically enter the scheduled start and stop time of the session, but do NOT include the actual session start and stop times of the therapy portion of that session, which should be recorded in the session note, and should be different for each session to be credible. Without this unique session documentation, the therapist has no proof that time requirements have been met for the CPT code used for that session. Look at the notes you are writing and ask yourself these questions:
Psychotherapy Notes
Psychotherapy notes are notes recorded by a behavioral health professional documenting and analyzing the contents of a conversation during a private counseling session or a group, joint, or family counseling session. Psychotherapy notes do not include information about medications, start and stop times, treatments, results of clinical tests, summary of diagnosis, functional status, treatment plans, symptoms, prognosis, and progress2. They are the personal notes of the provider and differ from progress notes which are part of the medical record. Psychotherapy notes are afforded a higher level of protection from disclosure than nonpsychotherapy documentation under HIPAA. However, they must be kept separate from the medical record. If they are intertwined, they lose that level of protection. If you are documenting in written format, keep psychotherapy notes separate from the record. This may be problematic as some EMR systems do not have the capability to separate out psychotherapy notes from the record. When using an EMR, be aware if the notes are separate or not. If your EMR system does not have the ability to separate out psychotherapy notes, keep separate written or electronic psychotherapy notes. If in electronic form, ensure they are safe, secure, and encrypted. If they are kept in written form, ensure they are secure and kept in a locked location. If you are unable to do either, you may consider not documenting psychotherapy notes in addition to the documentation in the patient’s medical record. Even if you do not document psychotherapy notes, you may be a professional who requests a record from another professional who does. Be aware if your state has a specific rule on psychotherapy notes as it could differ from the HIPAA rule. “Psychotherapy Notes” is a term coined by HIPAA. Although commonly referred to as “process notes” or “private notes,” HIPAA defines psychotherapy notes as “notes recorded (in any medium) … documenting or analyzing the contents of conversation during a private counseling session…that are separated from the rest of the individual’s medical record.” Kind of vague, right? The idea was to afford extra protection for a therapist’s personal notes, such as thoughts and feelings about a case, personal impressions of a client, or theoretical analysis of sessions (e.g., transference, resistance) that would not be appropriate as part of the client’s medical record. You may also record questions for future sessions, hunches and theories, areas for further exploration, and questions to bring up with a consultant. I think of them as kind of the therapist’s diary of the therapy. Psychotherapy notes are private and meant only for your reference, while progress notes are meant to be shared with other healthcare providers who are involved in a patient's care. Both types of notes are protected under HIPAA, but psychotherapy notes receive special protection because they can contain sensitive information. A few important things to know about Psychotherapy Notes:
You might have to share your psychotherapy notes if:
Progress Notes vs. Psychotherapy notes
Psychotherapy notes are private records meant to help therapists remember patient encounters. Progress notes, on the other hand, record information relevant to the patient’s treatment and response to treatment. This covers information such as diagnosis, symptoms, medical history, test results, treatment plan, progress at appointments, and prescription medications. Assessment
During the assessment process, the clinician should identify mental health symptoms that are serious enough to disrupt the client’s ability to cope and perform various age- and culturally-related social, personal, occupational, scholastic, or behavioral functions. The service provider should identify the client’s areas of life functioning that are impacted by their behavioral health. Examples are as follows:
Through assessment, you should be able to identify there is functional impairment present and should offer a diagnosis. The diagnosis should "result in functional impairment that substantially interferes with or limits one or more major life activities." Activity areas may include feeling, mood, and affect; thinking; family relationships; interpersonal relationships/social isolation; role/work performance; socio-legal conduct; and self-care/activities of daily living. Sample Assessment Note: Met with client today to discuss continued need for services. Discussed her current stressors, symptoms, and general functioning. She indicated that her anxiety symptoms (of being unable to go places because she continues to be afraid of large crowds) had increased this past month. She also stated that her mom’s health had declined, and she may have to move in with her. Clinician recommended individual therapy with frequency of one time per week. Intervention
If you check “CBT therapy,” “reflective listening,” and “exploration of feelings” as your interventions in the session notes EVERY WEEK, the reviewer has no sense that you are responding to the client’s unique issues of that session. A reviewer has no idea how you used CBT, what specific comments, interpretations, or advice you gave; homework you assigned; how you went about exploring the client’s feelings; and whether it was appropriate. And importantly, if that client were to file a complaint against you, those three checks will not defend you very well because they do not adequately reflect the details of the service you provided and how it was appropriate given the client’s presentation. Breaking Down the Progress Note
Time Session Started & Ended. If telehealth, did the Client confirm that they consented to telehealth? Where did the session take place? If telehealth, state location. If using telehealth for this session, was telehealth rendered via 2-way video/audio on a HIPAA compliant platform? Reason for Contact: Document the client’s reason for seeking treatment clearly, including condition(s) or complaint(s) presented during session. This needs to document why this service is necessary and is not to be confused with just a statement of a diagnosis. This might be a response, for example, to increased mental health acuity, problems in the home or in relationships, or problems with housing. As you write about the impairment, you want to be brief and clear, but you also want to include important details. The more specific you can be in your notes, the better. For example, if your client is experiencing symptoms of depression such as insomnia 6 nights a week, and their lack of sleep has impaired their ability to perform at work, you might say something like, “Because the client is experiencing insomnia six nights a week due to depression, they have missed eight days of work this month.” Overall, you want to focus on specific issues with functioning and list symptoms that impact important aspects of your client’s life. How do the client’s symptoms support their diagnosis? If you have increased or decreased how often you see the client, why? Intervention & Response: Be sure to use descriptive verbs to describe your interventions (i.e., what you did). Did you help the client cope/adapt/respond/problem solve? Did you teach/model/practice? Plan: This section outlines clinical assessment-informed treatment planning (i.e., what interventions you might try next), collateral contact, referrals to be made, follow-up items, homework assignments, and others. In the plan section, you should specify:
Sample Simple PRogress Note
Date of Session: August 23, 2024 Time of Session: 8:05 a.m. until 8:59 a.m. Location of Client: Client stated that they were in their home at their provided address Reason for Contact: Client continues to suffer from PTSD symptoms which make it difficult for her to work and sleep at night. She reports she can’t focus on her day-to-day tasks and is easily startled. She also continues to be scared at night. Intervention: Client came in stating that she continues to have nightmares of her husband being murdered in their home. She has difficulty getting to work and focusing on tasks. Client stated she is afraid of leaving the house at night or when it is dark outside. Clinician brainstormed with client how to increase her social support. Client stated she could connect with her church for emotional support. Problem solved with client on how to increase her amount of sleep. Discussed having her children visit her at night and to sleep with soothing music. Client agreed to work on finding more ways to socialize with her friends and leave the house to visit with her family during the day. She continues to decline referral to psychiatrist. Plan: Clinician will continue to meet with client weekly for Individual Therapy to work on established treatment goals. Will continue to encourage referrals to resources to increase client’s support network. Sample Language for Certain Diagnoses or Symptoms
See the tabs below for sample phrasing or language:
Anxiety
Depression
Trauma
Family Conflict
Descriptive Intervention Words for Progress Notes
When documenting therapeutic interventions in progress notes, it is essential to use descriptive and concise language to accurately capture the activities and techniques employed during a therapy session. The following include descriptive intervention words and phrases that can be helpful in progress note documentation:
Example Phrasing and Language for Progress Notes
Session Overview
Observations
Client's reported emotional state
Client Progress
Follow up Recommendations
Treatment Plan Adjustments
Clinical Interventions
Referrals
Homework
Treatment Plan
To be added. Treatman Plan Goals/objectives
Note: Always make objectives measurable (e.g., 3 out of 5 times, 100%, learn 3 skills), unless they are measurable on their own as in "List and discuss [issue] weekly... "
Abuse/Neglect
Goal: Explore and resolve issues relating to history of abuse/neglect victimization
Alcohol/drugs and other addictions
Goal: Be free of drug/alcohol use/abuse
anger
Goal: Increase and practice ability to manage anger
Anxiety
Goal: Develop strategies to reduce symptoms, or Reduce anxiety and improve coping skills
Behavior problems
Goal: Improve overall behavior (and attitude/mood), or Maintain positive behavior (and attitude/mood)
communication skills
Goal: Learn and use effective communication strategies
decision making
Goal: Improve decision making skills
Depression
Goal: Improve overall mood
eating disorder
Goal: Resolve eating disorder
expression of feelings, wants, and needs
Goal: Learn appropriate ways to express different feelings
family conflict
Goal: Learn and use conflict resolution skills
Grief and Loss
Goal: Explore and resolve grief and loss issues
Harm to self or others
Goal: Be free of thoughts of self-harm/self mutilation, or Be free of thoughts to harm to others
health issues
Goal: Manage physical healthcare conditions and cope with related stress
hyperactivity
Goal: Improve overall behavior, or Maintain positive behavior
medication management
Goal: Medication management
mood management
Goal: Maintain stability of mood, or Improve overall mood, or Maintain even mood, or Increase ability to manage moods.
parenting
Goal: Improve parenting skills
personal hygiene and self-care
Goal: Improve personal hygiene and attentiveness to independent/age appropriate self-care
physical health issues
Goal: Cope with stress of physical health issues and chronic pain
relationships
Goal: Establish/maintain civil and supportive behavior
school issues
self-image
Goal: Explore and resolve issues related to self image
Sleep Problems
Goal: Get 7-8 hours of restful sleep each night
Social skills
Goal: Improve social skills
Stress
Goal: Be able to cope with routine life stressors and take things in stride
Suicide
Goal: Be free of suicidal thoughts/attempts
Thought disorder
Goal: Improve ability to see world as others do
Trauma
Goal: Explore and resolve issues related to __________ (traumatic event)
Vocational/educational
Goal: Find a new job, or Keep present job, or Re-enter the work force
Treatment Plan Interventions
THE ELEMENTS OF A PROGRESS NOTE
Documenting medical necessity
It is the therapist's responsibility to communicate with the insurer about how the medical necessity criteria for therapy continues to be met through therapy. Although the medical necessity for medical issues tends to be more or less straightforward with the ways we objectively measure physical illness with tests, labs, or imaging, establishing medical necessity for mental health can sometimes be more challenging to objectively measure, quantify, or "prove" in the ways insurers, auditors, or others want to see it documented. "Medical necessity" is a term that often includes a specific set of criteria that insurance companies use to determine whether they are going to pay for a service. If an insurer deems a service "medically necessary," it means they agree the service is needed and clinically agree to pay for it. However, clinical approval is not a complete guarantee of payment. This is caused by other administrative processes like coding, timeliness, network rules, etc. that could interfere with reimbursement. Insurance is fixated on improvements in the cheapest way possible. Most insurers understand the value of psychotherapy, at least in terms of a low-cost intervention to the general well-being of individuals, and especially in comparison to higher-cost services like those in a hospital setting. Insurance does not necessarily care about which evidence-based treatment you are using. It is a myth that your notes or documentation have to "look like CBT," for example. Insurers want to pay for (and see documented) the things you need a master's degree or Ph.D. to administer. Elements like empathy, active listening, reflecting, paraphrasing, support, and person-centered interventions will not be well received. The best way to navigate medical necessity is by having clear documentation from the very beginning or first session of treatment. It is extremely difficult to know the nuances of what each insurer wants to see. Medical necessity and legal documentation are broken down into a few areas:
Progress Notes
“Progress notes” — as defined by the Health Information Portability and Accountability Act (HIPAA) — are a REQUIRED part of the client’s medical record and reflect what occurred in each visit. HIPAA states they may include assessment and diagnosis, treatment modality and frequency, session start/stop times, topics discussed, interventions, medication monitoring, test results, summaries of functioning, symptoms, prognosis, and progress.
Progress Note Template Many templates automatically enter the scheduled start and stop time of the session, but do NOT include the actual session start and stop times of the therapy portion of that session, which should be recorded in the session note, and should be different for each session to be credible. Without this unique session documentation, the therapist has no proof that time requirements have been met for the CPT code used for that session. Look at the notes you are writing and ask yourself these questions:
Psychotherapy Notes
Psychotherapy notes are notes recorded by a behavioral health professional documenting and analyzing the contents of a conversation during a private counseling session or a group, joint, or family counseling session. Psychotherapy notes do not include information about medications, start and stop times, treatments, results of clinical tests, summary of diagnosis, functional status, treatment plans, symptoms, prognosis, and progress2. They are the personal notes of the provider and differ from progress notes which are part of the medical record. Psychotherapy notes are afforded a higher level of protection from disclosure than nonpsychotherapy documentation under HIPAA. However, they must be kept separate from the medical record. If they are intertwined, they lose that level of protection. If you are documenting in written format, keep psychotherapy notes separate from the record. This may be problematic as some EMR systems do not have the capability to separate out psychotherapy notes from the record. When using an EMR, be aware if the notes are separate or not. If your EMR system does not have the ability to separate out psychotherapy notes, keep separate written or electronic psychotherapy notes. If in electronic form, ensure they are safe, secure, and encrypted. If they are kept in written form, ensure they are secure and kept in a locked location. If you are unable to do either, you may consider not documenting psychotherapy notes in addition to the documentation in the patient’s medical record. Even if you do not document psychotherapy notes, you may be a professional who requests a record from another professional who does. Be aware if your state has a specific rule on psychotherapy notes as it could differ from the HIPAA rule. “Psychotherapy Notes” is a term coined by HIPAA. Although commonly referred to as “process notes” or “private notes,” HIPAA defines psychotherapy notes as “notes recorded (in any medium) … documenting or analyzing the contents of conversation during a private counseling session…that are separated from the rest of the individual’s medical record.” Kind of vague, right? The idea was to afford extra protection for a therapist’s personal notes, such as thoughts and feelings about a case, personal impressions of a client, or theoretical analysis of sessions (e.g., transference, resistance) that would not be appropriate as part of the client’s medical record. You may also record questions for future sessions, hunches and theories, areas for further exploration, and questions to bring up with a consultant. I think of them as kind of the therapist’s diary of the therapy. Psychotherapy notes are private and meant only for your reference, while progress notes are meant to be shared with other healthcare providers who are involved in a patient's care. Both types of notes are protected under HIPAA, but psychotherapy notes receive special protection because they can contain sensitive information. A few important things to know about Psychotherapy Notes:
You might have to share your psychotherapy notes if:
Progress Notes vs. Psychotherapy notes
Psychotherapy notes are private records meant to help therapists remember patient encounters. Progress notes, on the other hand, record information relevant to the patient’s treatment and response to treatment. This covers information such as diagnosis, symptoms, medical history, test results, treatment plan, progress at appointments, and prescription medications. Assessment
During the assessment process, the clinician should identify mental health symptoms that are serious enough to disrupt the client’s ability to cope and perform various age- and culturally-related social, personal, occupational, scholastic, or behavioral functions. The service provider should identify the client’s areas of life functioning that are impacted by their behavioral health. Examples are as follows:
Through assessment, you should be able to identify there is functional impairment present and should offer a diagnosis. The diagnosis should "result in functional impairment that substantially interferes with or limits one or more major life activities." Activity areas may include feeling, mood, and affect; thinking; family relationships; interpersonal relationships/social isolation; role/work performance; socio-legal conduct; and self-care/activities of daily living. Sample Assessment Note: Met with client today to discuss continued need for services. Discussed her current stressors, symptoms, and general functioning. She indicated that her anxiety symptoms (of being unable to go places because she continues to be afraid of large crowds) had increased this past month. She also stated that her mom’s health had declined, and she may have to move in with her. Clinician recommended individual therapy with frequency of one time per week. Intervention
If you check “CBT therapy,” “reflective listening,” and “exploration of feelings” as your interventions in the session notes EVERY WEEK, the reviewer has no sense that you are responding to the client’s unique issues of that session. A reviewer has no idea how you used CBT, what specific comments, interpretations, or advice you gave; homework you assigned; how you went about exploring the client’s feelings; and whether it was appropriate. And importantly, if that client were to file a complaint against you, those three checks will not defend you very well because they do not adequately reflect the details of the service you provided and how it was appropriate given the client’s presentation. Breaking Down the Progress Note
Time Session Started & Ended. If telehealth, did the Client confirm that they consented to telehealth? Where did the session take place? If telehealth, state location. If using telehealth for this session, was telehealth rendered via 2-way video/audio on a HIPAA compliant platform? Reason for Contact: Document the client’s reason for seeking treatment clearly, including condition(s) or complaint(s) presented during session. This needs to document why this service is necessary and is not to be confused with just a statement of a diagnosis. This might be a response, for example, to increased mental health acuity, problems in the home or in relationships, or problems with housing. As you write about the impairment, you want to be brief and clear, but you also want to include important details. The more specific you can be in your notes, the better. For example, if your client is experiencing symptoms of depression such as insomnia 6 nights a week, and their lack of sleep has impaired their ability to perform at work, you might say something like, “Because the client is experiencing insomnia six nights a week due to depression, they have missed eight days of work this month.” Overall, you want to focus on specific issues with functioning and list symptoms that impact important aspects of your client’s life. How do the client’s symptoms support their diagnosis? If you have increased or decreased how often you see the client, why? Intervention & Response: Be sure to use descriptive verbs to describe your interventions (i.e., what you did). Did you help the client cope/adapt/respond/problem solve? Did you teach/model/practice? Plan: This section outlines clinical assessment-informed treatment planning (i.e., what interventions you might try next), collateral contact, referrals to be made, follow-up items, homework assignments, and others. In the plan section, you should specify:
Sample Simple PRogress Note
Date of Session: August 23, 2024 Time of Session: 8:05 a.m. until 8:59 a.m. Location of Client: Client stated that they were in their home at their provided address Reason for Contact: Client continues to suffer from PTSD symptoms which make it difficult for her to work and sleep at night. She reports she can’t focus on her day-to-day tasks and is easily startled. She also continues to be scared at night. Intervention: Client came in stating that she continues to have nightmares of her husband being murdered in their home. She has difficulty getting to work and focusing on tasks. Client stated she is afraid of leaving the house at night or when it is dark outside. Clinician brainstormed with client how to increase her social support. Client stated she could connect with her church for emotional support. Problem solved with client on how to increase her amount of sleep. Discussed having her children visit her at night and to sleep with soothing music. Client agreed to work on finding more ways to socialize with her friends and leave the house to visit with her family during the day. She continues to decline referral to psychiatrist. Plan: Clinician will continue to meet with client weekly for Individual Therapy to work on established treatment goals. Will continue to encourage referrals to resources to increase client’s support network. Sample Language for Certain Diagnoses or Symptoms
See the tabs below for sample phrasing or language:
Anxiety
Depression
Trauma
Family Conflict
Descriptive Intervention Words for Progress Notes
When documenting therapeutic interventions in progress notes, it is essential to use descriptive and concise language to accurately capture the activities and techniques employed during a therapy session. The following include descriptive intervention words and phrases that can be helpful in progress note documentation:
Example Phrasing and Language for Progress Notes
Session Overview
Observations
Client's reported emotional state
Client Progress
Follow up Recommendations
Treatment Plan Adjustments
Clinical Interventions
Referrals
Homework
Treatment Plan
To be added. Treatman Plan Goals/objectives
Note: Always make objectives measurable (e.g., 3 out of 5 times, 100%, learn 3 skills), unless they are measurable on their own as in "List and discuss [issue] weekly... "
Abuse/Neglect
Goal: Explore and resolve issues relating to history of abuse/neglect victimization
Alcohol/drugs and other addictions
Goal: Be free of drug/alcohol use/abuse
anger
Goal: Increase and practice ability to manage anger
Anxiety
Goal: Develop strategies to reduce symptoms, or Reduce anxiety and improve coping skills
Behavior problems
Goal: Improve overall behavior (and attitude/mood), or Maintain positive behavior (and attitude/mood)
communication skills
Goal: Learn and use effective communication strategies
decision making
Goal: Improve decision making skills
Depression
Goal: Improve overall mood
eating disorder
Goal: Resolve eating disorder
expression of feelings, wants, and needs
Goal: Learn appropriate ways to express different feelings
family conflict
Goal: Learn and use conflict resolution skills
Grief and Loss
Goal: Explore and resolve grief and loss issues
Harm to self or others
Goal: Be free of thoughts of self-harm/self mutilation, or Be free of thoughts to harm to others
health issues
Goal: Manage physical healthcare conditions and cope with related stress
hyperactivity
Goal: Improve overall behavior, or Maintain positive behavior
medication management
Goal: Medication management
mood management
Goal: Maintain stability of mood, or Improve overall mood, or Maintain even mood, or Increase ability to manage moods.
parenting
Goal: Improve parenting skills
personal hygiene and self-care
Goal: Improve personal hygiene and attentiveness to independent/age appropriate self-care
physical health issues
Goal: Cope with stress of physical health issues and chronic pain
relationships
Goal: Establish/maintain civil and supportive behavior
school issues
self-image
Goal: Explore and resolve issues related to self image
Sleep Problems
Goal: Get 7-8 hours of restful sleep each night
Social skills
Goal: Improve social skills
Stress
Goal: Be able to cope with routine life stressors and take things in stride
Suicide
Goal: Be free of suicidal thoughts/attempts
Thought disorder
Goal: Improve ability to see world as others do
Trauma
Goal: Explore and resolve issues related to __________ (traumatic event)
Vocational/educational
Goal: Find a new job, or Keep present job, or Re-enter the work force
Treatment Plan Interventions
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Documenting medical necessity
It is the therapist's responsibility to communicate with the insurer about how the medical necessity criteria for therapy continues to be met through therapy. Although the medical necessity for medical issues tends to be more or less straightforward with the ways we objectively measure physical illness with tests, labs, or imaging, establishing medical necessity for mental health can sometimes be more challenging to objectively measure, quantify, or "prove" in the ways insurers, auditors, or others want to see it documented. "Medical necessity" is a term that often includes a specific set of criteria that insurance companies use to determine whether they are going to pay for a service. If an insurer deems a service "medically necessary," it means they agree the service is needed and clinically agree to pay for it. However, clinical approval is not a complete guarantee of payment. This is caused by other administrative processes like coding, timeliness, network rules, etc. that could interfere with reimbursement. Insurance is fixated on improvements in the cheapest way possible. Most insurers understand the value of psychotherapy, at least in terms of a low-cost intervention to the general well-being of individuals, and especially in comparison to higher-cost services like those in a hospital setting. Insurance does not necessarily care about which evidence-based treatment you are using. It is a myth that your notes or documentation have to "look like CBT," for example. Insurers want to pay for (and see documented) the things you need a master's degree or Ph.D. to administer. Elements like empathy, active listening, reflecting, paraphrasing, support, and person-centered interventions will not be well received. The best way to navigate medical necessity is by having clear documentation from the very beginning or first session of treatment. It is extremely difficult to know the nuances of what each insurer wants to see. Medical necessity and legal documentation are broken down into a few areas:
Progress Notes
“Progress notes” — as defined by the Health Information Portability and Accountability Act (HIPAA) — are a REQUIRED part of the client’s medical record and reflect what occurred in each visit. HIPAA states they may include assessment and diagnosis, treatment modality and frequency, session start/stop times, topics discussed, interventions, medication monitoring, test results, summaries of functioning, symptoms, prognosis, and progress.
Progress Note Template Many templates automatically enter the scheduled start and stop time of the session, but do NOT include the actual session start and stop times of the therapy portion of that session, which should be recorded in the session note, and should be different for each session to be credible. Without this unique session documentation, the therapist has no proof that time requirements have been met for the CPT code used for that session. Look at the notes you are writing and ask yourself these questions:
Psychotherapy Notes
Psychotherapy notes are notes recorded by a behavioral health professional documenting and analyzing the contents of a conversation during a private counseling session or a group, joint, or family counseling session. Psychotherapy notes do not include information about medications, start and stop times, treatments, results of clinical tests, summary of diagnosis, functional status, treatment plans, symptoms, prognosis, and progress2. They are the personal notes of the provider and differ from progress notes which are part of the medical record. Psychotherapy notes are afforded a higher level of protection from disclosure than nonpsychotherapy documentation under HIPAA. However, they must be kept separate from the medical record. If they are intertwined, they lose that level of protection. If you are documenting in written format, keep psychotherapy notes separate from the record. This may be problematic as some EMR systems do not have the capability to separate out psychotherapy notes from the record. When using an EMR, be aware if the notes are separate or not. If your EMR system does not have the ability to separate out psychotherapy notes, keep separate written or electronic psychotherapy notes. If in electronic form, ensure they are safe, secure, and encrypted. If they are kept in written form, ensure they are secure and kept in a locked location. If you are unable to do either, you may consider not documenting psychotherapy notes in addition to the documentation in the patient’s medical record. Even if you do not document psychotherapy notes, you may be a professional who requests a record from another professional who does. Be aware if your state has a specific rule on psychotherapy notes as it could differ from the HIPAA rule. “Psychotherapy Notes” is a term coined by HIPAA. Although commonly referred to as “process notes” or “private notes,” HIPAA defines psychotherapy notes as “notes recorded (in any medium) … documenting or analyzing the contents of conversation during a private counseling session…that are separated from the rest of the individual’s medical record.” Kind of vague, right? The idea was to afford extra protection for a therapist’s personal notes, such as thoughts and feelings about a case, personal impressions of a client, or theoretical analysis of sessions (e.g., transference, resistance) that would not be appropriate as part of the client’s medical record. You may also record questions for future sessions, hunches and theories, areas for further exploration, and questions to bring up with a consultant. I think of them as kind of the therapist’s diary of the therapy. Psychotherapy notes are private and meant only for your reference, while progress notes are meant to be shared with other healthcare providers who are involved in a patient's care. Both types of notes are protected under HIPAA, but psychotherapy notes receive special protection because they can contain sensitive information. A few important things to know about Psychotherapy Notes:
You might have to share your psychotherapy notes if:
Progress Notes vs. Psychotherapy notes
Psychotherapy notes are private records meant to help therapists remember patient encounters. Progress notes, on the other hand, record information relevant to the patient’s treatment and response to treatment. This covers information such as diagnosis, symptoms, medical history, test results, treatment plan, progress at appointments, and prescription medications. Assessment
During the assessment process, the clinician should identify mental health symptoms that are serious enough to disrupt the client’s ability to cope and perform various age- and culturally-related social, personal, occupational, scholastic, or behavioral functions. The service provider should identify the client’s areas of life functioning that are impacted by their behavioral health. Examples are as follows:
Through assessment, you should be able to identify there is functional impairment present and should offer a diagnosis. The diagnosis should "result in functional impairment that substantially interferes with or limits one or more major life activities." Activity areas may include feeling, mood, and affect; thinking; family relationships; interpersonal relationships/social isolation; role/work performance; socio-legal conduct; and self-care/activities of daily living. Sample Assessment Note: Met with client today to discuss continued need for services. Discussed her current stressors, symptoms, and general functioning. She indicated that her anxiety symptoms (of being unable to go places because she continues to be afraid of large crowds) had increased this past month. She also stated that her mom’s health had declined, and she may have to move in with her. Clinician recommended individual therapy with frequency of one time per week. Intervention
If you check “CBT therapy,” “reflective listening,” and “exploration of feelings” as your interventions in the session notes EVERY WEEK, the reviewer has no sense that you are responding to the client’s unique issues of that session. A reviewer has no idea how you used CBT, what specific comments, interpretations, or advice you gave; homework you assigned; how you went about exploring the client’s feelings; and whether it was appropriate. And importantly, if that client were to file a complaint against you, those three checks will not defend you very well because they do not adequately reflect the details of the service you provided and how it was appropriate given the client’s presentation. Breaking Down the Progress Note
Time Session Started & Ended. If telehealth, did the Client confirm that they consented to telehealth? Where did the session take place? If telehealth, state location. If using telehealth for this session, was telehealth rendered via 2-way video/audio on a HIPAA compliant platform? Reason for Contact: Document the client’s reason for seeking treatment clearly, including condition(s) or complaint(s) presented during session. This needs to document why this service is necessary and is not to be confused with just a statement of a diagnosis. This might be a response, for example, to increased mental health acuity, problems in the home or in relationships, or problems with housing. As you write about the impairment, you want to be brief and clear, but you also want to include important details. The more specific you can be in your notes, the better. For example, if your client is experiencing symptoms of depression such as insomnia 6 nights a week, and their lack of sleep has impaired their ability to perform at work, you might say something like, “Because the client is experiencing insomnia six nights a week due to depression, they have missed eight days of work this month.” Overall, you want to focus on specific issues with functioning and list symptoms that impact important aspects of your client’s life. How do the client’s symptoms support their diagnosis? If you have increased or decreased how often you see the client, why? Intervention & Response: Be sure to use descriptive verbs to describe your interventions (i.e., what you did). Did you help the client cope/adapt/respond/problem solve? Did you teach/model/practice? Plan: This section outlines clinical assessment-informed treatment planning (i.e., what interventions you might try next), collateral contact, referrals to be made, follow-up items, homework assignments, and others. In the plan section, you should specify:
Sample Simple PRogress Note
Date of Session: August 23, 2024 Time of Session: 8:05 a.m. until 8:59 a.m. Location of Client: Client stated that they were in their home at their provided address Reason for Contact: Client continues to suffer from PTSD symptoms which make it difficult for her to work and sleep at night. She reports she can’t focus on her day-to-day tasks and is easily startled. She also continues to be scared at night. Intervention: Client came in stating that she continues to have nightmares of her husband being murdered in their home. She has difficulty getting to work and focusing on tasks. Client stated she is afraid of leaving the house at night or when it is dark outside. Clinician brainstormed with client how to increase her social support. Client stated she could connect with her church for emotional support. Problem solved with client on how to increase her amount of sleep. Discussed having her children visit her at night and to sleep with soothing music. Client agreed to work on finding more ways to socialize with her friends and leave the house to visit with her family during the day. She continues to decline referral to psychiatrist. Plan: Clinician will continue to meet with client weekly for Individual Therapy to work on established treatment goals. Will continue to encourage referrals to resources to increase client’s support network. Sample Language for Certain Diagnoses or Symptoms
See the tabs below for sample phrasing or language:
Anxiety
Depression
Trauma
Family Conflict
Descriptive Intervention Words for Progress Notes
When documenting therapeutic interventions in progress notes, it is essential to use descriptive and concise language to accurately capture the activities and techniques employed during a therapy session. The following include descriptive intervention words and phrases that can be helpful in progress note documentation:
Example Phrasing and Language for Progress Notes
Session Overview
Observations
Client's reported emotional state
Client Progress
Follow up Recommendations
Treatment Plan Adjustments
Clinical Interventions
Referrals
Homework
Treatment Plan
To be added. Treatman Plan Goals/objectives
Note: Always make objectives measurable (e.g., 3 out of 5 times, 100%, learn 3 skills), unless they are measurable on their own as in "List and discuss [issue] weekly... "
Abuse/Neglect
Goal: Explore and resolve issues relating to history of abuse/neglect victimization
Alcohol/drugs and other addictions
Goal: Be free of drug/alcohol use/abuse
anger
Goal: Increase and practice ability to manage anger
Anxiety
Goal: Develop strategies to reduce symptoms, or Reduce anxiety and improve coping skills
Behavior problems
Goal: Improve overall behavior (and attitude/mood), or Maintain positive behavior (and attitude/mood)
communication skills
Goal: Learn and use effective communication strategies
decision making
Goal: Improve decision making skills
Depression
Goal: Improve overall mood
eating disorder
Goal: Resolve eating disorder
expression of feelings, wants, and needs
Goal: Learn appropriate ways to express different feelings
family conflict
Goal: Learn and use conflict resolution skills
Grief and Loss
Goal: Explore and resolve grief and loss issues
Harm to self or others
Goal: Be free of thoughts of self-harm/self mutilation, or Be free of thoughts to harm to others
health issues
Goal: Manage physical healthcare conditions and cope with related stress
hyperactivity
Goal: Improve overall behavior, or Maintain positive behavior
medication management
Goal: Medication management
mood management
Goal: Maintain stability of mood, or Improve overall mood, or Maintain even mood, or Increase ability to manage moods.
parenting
Goal: Improve parenting skills
personal hygiene and self-care
Goal: Improve personal hygiene and attentiveness to independent/age appropriate self-care
physical health issues
Goal: Cope with stress of physical health issues and chronic pain
relationships
Goal: Establish/maintain civil and supportive behavior
school issues
self-image
Goal: Explore and resolve issues related to self image
Sleep Problems
Goal: Get 7-8 hours of restful sleep each night
Social skills
Goal: Improve social skills
Stress
Goal: Be able to cope with routine life stressors and take things in stride
Suicide
Goal: Be free of suicidal thoughts/attempts
Thought disorder
Goal: Improve ability to see world as others do
Trauma
Goal: Explore and resolve issues related to __________ (traumatic event)
Vocational/educational
Goal: Find a new job, or Keep present job, or Re-enter the work force
Treatment Plan Interventions
INTERVENTIONS & TOOLS
Documenting medical necessity
It is the therapist's responsibility to communicate with the insurer about how the medical necessity criteria for therapy continues to be met through therapy. Although the medical necessity for medical issues tends to be more or less straightforward with the ways we objectively measure physical illness with tests, labs, or imaging, establishing medical necessity for mental health can sometimes be more challenging to objectively measure, quantify, or "prove" in the ways insurers, auditors, or others want to see it documented. "Medical necessity" is a term that often includes a specific set of criteria that insurance companies use to determine whether they are going to pay for a service. If an insurer deems a service "medically necessary," it means they agree the service is needed and clinically agree to pay for it. However, clinical approval is not a complete guarantee of payment. This is caused by other administrative processes like coding, timeliness, network rules, etc. that could interfere with reimbursement. Insurance is fixated on improvements in the cheapest way possible. Most insurers understand the value of psychotherapy, at least in terms of a low-cost intervention to the general well-being of individuals, and especially in comparison to higher-cost services like those in a hospital setting. Insurance does not necessarily care about which evidence-based treatment you are using. It is a myth that your notes or documentation have to "look like CBT," for example. Insurers want to pay for (and see documented) the things you need a master's degree or Ph.D. to administer. Elements like empathy, active listening, reflecting, paraphrasing, support, and person-centered interventions will not be well received. The best way to navigate medical necessity is by having clear documentation from the very beginning or first session of treatment. It is extremely difficult to know the nuances of what each insurer wants to see. Medical necessity and legal documentation are broken down into a few areas:
Progress Notes
“Progress notes” — as defined by the Health Information Portability and Accountability Act (HIPAA) — are a REQUIRED part of the client’s medical record and reflect what occurred in each visit. HIPAA states they may include assessment and diagnosis, treatment modality and frequency, session start/stop times, topics discussed, interventions, medication monitoring, test results, summaries of functioning, symptoms, prognosis, and progress.
Progress Note Template Many templates automatically enter the scheduled start and stop time of the session, but do NOT include the actual session start and stop times of the therapy portion of that session, which should be recorded in the session note, and should be different for each session to be credible. Without this unique session documentation, the therapist has no proof that time requirements have been met for the CPT code used for that session. Look at the notes you are writing and ask yourself these questions:
Psychotherapy Notes
Psychotherapy notes are notes recorded by a behavioral health professional documenting and analyzing the contents of a conversation during a private counseling session or a group, joint, or family counseling session. Psychotherapy notes do not include information about medications, start and stop times, treatments, results of clinical tests, summary of diagnosis, functional status, treatment plans, symptoms, prognosis, and progress2. They are the personal notes of the provider and differ from progress notes which are part of the medical record. Psychotherapy notes are afforded a higher level of protection from disclosure than nonpsychotherapy documentation under HIPAA. However, they must be kept separate from the medical record. If they are intertwined, they lose that level of protection. If you are documenting in written format, keep psychotherapy notes separate from the record. This may be problematic as some EMR systems do not have the capability to separate out psychotherapy notes from the record. When using an EMR, be aware if the notes are separate or not. If your EMR system does not have the ability to separate out psychotherapy notes, keep separate written or electronic psychotherapy notes. If in electronic form, ensure they are safe, secure, and encrypted. If they are kept in written form, ensure they are secure and kept in a locked location. If you are unable to do either, you may consider not documenting psychotherapy notes in addition to the documentation in the patient’s medical record. Even if you do not document psychotherapy notes, you may be a professional who requests a record from another professional who does. Be aware if your state has a specific rule on psychotherapy notes as it could differ from the HIPAA rule. “Psychotherapy Notes” is a term coined by HIPAA. Although commonly referred to as “process notes” or “private notes,” HIPAA defines psychotherapy notes as “notes recorded (in any medium) … documenting or analyzing the contents of conversation during a private counseling session…that are separated from the rest of the individual’s medical record.” Kind of vague, right? The idea was to afford extra protection for a therapist’s personal notes, such as thoughts and feelings about a case, personal impressions of a client, or theoretical analysis of sessions (e.g., transference, resistance) that would not be appropriate as part of the client’s medical record. You may also record questions for future sessions, hunches and theories, areas for further exploration, and questions to bring up with a consultant. I think of them as kind of the therapist’s diary of the therapy. Psychotherapy notes are private and meant only for your reference, while progress notes are meant to be shared with other healthcare providers who are involved in a patient's care. Both types of notes are protected under HIPAA, but psychotherapy notes receive special protection because they can contain sensitive information. A few important things to know about Psychotherapy Notes:
You might have to share your psychotherapy notes if:
Progress Notes vs. Psychotherapy notes
Psychotherapy notes are private records meant to help therapists remember patient encounters. Progress notes, on the other hand, record information relevant to the patient’s treatment and response to treatment. This covers information such as diagnosis, symptoms, medical history, test results, treatment plan, progress at appointments, and prescription medications. Assessment
During the assessment process, the clinician should identify mental health symptoms that are serious enough to disrupt the client’s ability to cope and perform various age- and culturally-related social, personal, occupational, scholastic, or behavioral functions. The service provider should identify the client’s areas of life functioning that are impacted by their behavioral health. Examples are as follows:
Through assessment, you should be able to identify there is functional impairment present and should offer a diagnosis. The diagnosis should "result in functional impairment that substantially interferes with or limits one or more major life activities." Activity areas may include feeling, mood, and affect; thinking; family relationships; interpersonal relationships/social isolation; role/work performance; socio-legal conduct; and self-care/activities of daily living. Sample Assessment Note: Met with client today to discuss continued need for services. Discussed her current stressors, symptoms, and general functioning. She indicated that her anxiety symptoms (of being unable to go places because she continues to be afraid of large crowds) had increased this past month. She also stated that her mom’s health had declined, and she may have to move in with her. Clinician recommended individual therapy with frequency of one time per week. Intervention
If you check “CBT therapy,” “reflective listening,” and “exploration of feelings” as your interventions in the session notes EVERY WEEK, the reviewer has no sense that you are responding to the client’s unique issues of that session. A reviewer has no idea how you used CBT, what specific comments, interpretations, or advice you gave; homework you assigned; how you went about exploring the client’s feelings; and whether it was appropriate. And importantly, if that client were to file a complaint against you, those three checks will not defend you very well because they do not adequately reflect the details of the service you provided and how it was appropriate given the client’s presentation. Breaking Down the Progress Note
Time Session Started & Ended. If telehealth, did the Client confirm that they consented to telehealth? Where did the session take place? If telehealth, state location. If using telehealth for this session, was telehealth rendered via 2-way video/audio on a HIPAA compliant platform? Reason for Contact: Document the client’s reason for seeking treatment clearly, including condition(s) or complaint(s) presented during session. This needs to document why this service is necessary and is not to be confused with just a statement of a diagnosis. This might be a response, for example, to increased mental health acuity, problems in the home or in relationships, or problems with housing. As you write about the impairment, you want to be brief and clear, but you also want to include important details. The more specific you can be in your notes, the better. For example, if your client is experiencing symptoms of depression such as insomnia 6 nights a week, and their lack of sleep has impaired their ability to perform at work, you might say something like, “Because the client is experiencing insomnia six nights a week due to depression, they have missed eight days of work this month.” Overall, you want to focus on specific issues with functioning and list symptoms that impact important aspects of your client’s life. How do the client’s symptoms support their diagnosis? If you have increased or decreased how often you see the client, why? Intervention & Response: Be sure to use descriptive verbs to describe your interventions (i.e., what you did). Did you help the client cope/adapt/respond/problem solve? Did you teach/model/practice? Plan: This section outlines clinical assessment-informed treatment planning (i.e., what interventions you might try next), collateral contact, referrals to be made, follow-up items, homework assignments, and others. In the plan section, you should specify:
Sample Simple PRogress Note
Date of Session: August 23, 2024 Time of Session: 8:05 a.m. until 8:59 a.m. Location of Client: Client stated that they were in their home at their provided address Reason for Contact: Client continues to suffer from PTSD symptoms which make it difficult for her to work and sleep at night. She reports she can’t focus on her day-to-day tasks and is easily startled. She also continues to be scared at night. Intervention: Client came in stating that she continues to have nightmares of her husband being murdered in their home. She has difficulty getting to work and focusing on tasks. Client stated she is afraid of leaving the house at night or when it is dark outside. Clinician brainstormed with client how to increase her social support. Client stated she could connect with her church for emotional support. Problem solved with client on how to increase her amount of sleep. Discussed having her children visit her at night and to sleep with soothing music. Client agreed to work on finding more ways to socialize with her friends and leave the house to visit with her family during the day. She continues to decline referral to psychiatrist. Plan: Clinician will continue to meet with client weekly for Individual Therapy to work on established treatment goals. Will continue to encourage referrals to resources to increase client’s support network. Sample Language for Certain Diagnoses or Symptoms
See the tabs below for sample phrasing or language:
Anxiety
Depression
Trauma
Family Conflict
Descriptive Intervention Words for Progress Notes
When documenting therapeutic interventions in progress notes, it is essential to use descriptive and concise language to accurately capture the activities and techniques employed during a therapy session. The following include descriptive intervention words and phrases that can be helpful in progress note documentation:
Example Phrasing and Language for Progress Notes
Session Overview
Observations
Client's reported emotional state
Client Progress
Follow up Recommendations
Treatment Plan Adjustments
Clinical Interventions
Referrals
Homework
Treatment Plan
To be added. Treatman Plan Goals/objectives
Note: Always make objectives measurable (e.g., 3 out of 5 times, 100%, learn 3 skills), unless they are measurable on their own as in "List and discuss [issue] weekly... "
Abuse/Neglect
Goal: Explore and resolve issues relating to history of abuse/neglect victimization
Alcohol/drugs and other addictions
Goal: Be free of drug/alcohol use/abuse
anger
Goal: Increase and practice ability to manage anger
Anxiety
Goal: Develop strategies to reduce symptoms, or Reduce anxiety and improve coping skills
Behavior problems
Goal: Improve overall behavior (and attitude/mood), or Maintain positive behavior (and attitude/mood)
communication skills
Goal: Learn and use effective communication strategies
decision making
Goal: Improve decision making skills
Depression
Goal: Improve overall mood
eating disorder
Goal: Resolve eating disorder
expression of feelings, wants, and needs
Goal: Learn appropriate ways to express different feelings
family conflict
Goal: Learn and use conflict resolution skills
Grief and Loss
Goal: Explore and resolve grief and loss issues
Harm to self or others
Goal: Be free of thoughts of self-harm/self mutilation, or Be free of thoughts to harm to others
health issues
Goal: Manage physical healthcare conditions and cope with related stress
hyperactivity
Goal: Improve overall behavior, or Maintain positive behavior
medication management
Goal: Medication management
mood management
Goal: Maintain stability of mood, or Improve overall mood, or Maintain even mood, or Increase ability to manage moods.
parenting
Goal: Improve parenting skills
personal hygiene and self-care
Goal: Improve personal hygiene and attentiveness to independent/age appropriate self-care
physical health issues
Goal: Cope with stress of physical health issues and chronic pain
relationships
Goal: Establish/maintain civil and supportive behavior
school issues
self-image
Goal: Explore and resolve issues related to self image
Sleep Problems
Goal: Get 7-8 hours of restful sleep each night
Social skills
Goal: Improve social skills
Stress
Goal: Be able to cope with routine life stressors and take things in stride
Suicide
Goal: Be free of suicidal thoughts/attempts
Thought disorder
Goal: Improve ability to see world as others do
Trauma
Goal: Explore and resolve issues related to __________ (traumatic event)
Vocational/educational
Goal: Find a new job, or Keep present job, or Re-enter the work force
Treatment Plan Interventions
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FAQs
IS AN ADDENDUM OR CORRECTION OKAY?
The short answer is, yes, an addendum or correction is okay, and actually is needed to clarify the care or to correct misinformation. It must be clear, however, that your addition to your previous note is an addendum or correction. Avoid an addendum or correction that may appear self-serving or is not substantive. Never erase or destroy the original note in a record. If using an EMR, your initial documentation may still appear in the record in crossed out form so any third party reading the record can still see the original documentation as well as the addendum or correction. Always note the reason for the addendum or correction and the date it was made
When Should I document Timing?
Determining when to document timing is a common issue many allied healthcare professionals face. You may face a myriad of daily occurrences that impact your ability to document. Some of these occurrences might include mounting requirements from insurers, back-to-back scheduled patients, emergency issues, phone calls for prior authorization, or other issues that occur daily.
You may think, “I will get to this later.” However, it is important to document as close in time to the patient appointment as possible. Say, for example, you were unable to document a patient’s appointment until the following day, and the patient goes home and contacts you to indicate an issue occurred. It is far better to have documented the encounter and then add an addendum when the patient contacts you rather than documenting both all in one note. Likely, if you are using an EMR, your note will be time-stamped, so it will reflect when the documentation actually occurred.
You may think, “I will get to this later.” However, it is important to document as close in time to the patient appointment as possible. Say, for example, you were unable to document a patient’s appointment until the following day, and the patient goes home and contacts you to indicate an issue occurred. It is far better to have documented the encounter and then add an addendum when the patient contacts you rather than documenting both all in one note. Likely, if you are using an EMR, your note will be time-stamped, so it will reflect when the documentation actually occurred.
What Should I avoid in documentation?
There are times you may need to be cautious about what to document. As mentioned, check to see if your state has rules about documenting information on third parties, including names, and if there are rules indicating a third party may have a claim against you if you release records with his/her name, even if the person is not your patient. Seek guidance if necessary. In addition, the following items are a few things to potentially avoid (keeping in mind this depends upon the patient and the circumstance):
- Abbreviations that differ from the acceptable, standard abbreviations
- Blank spaces/pages when documenting in written form
- An informal or curbside consult. Unlike formal consultations, informal consultations are not typically documented. This is not across the board and may vary depending on your facility.
- Avoid documenting words such as “error,” “mistake,” “accident”
- Issues that are not vital to treatment
- Subjective documentation (as indicated above)
- Finger pointing or placing blame on another provider
do I need to include text or email communication in my documentation?
TEXTING:
If you engage in text communication with patients, you should first have an office policy concerning when it is appropriate for clients to communicate with you via text and a signed informed consent document that highlights possible privacy concerns when using text messages. It is important to have consistent rules about what types of communications patients are able to communicate with you via text.
Also, you cannot ensure a party other than your client may receive your text. They may leave their phone on the counter, table, or unattended meaning that the text you send may not be received by your client. These risks should be addressed in your informed consent with the client.
Make sure you take a screenshot of any text communication to memorialize in the record. If it becomes apparent that you cannot continue to communicate with your patient via text, for whatever reason, ensure the process for ending such communication is incorporated within your policy, and ensure you memorialize this change by sending a letter to the patient that texting is no longer able to be used.
If an emergency issue arises over texting, be aware of how to seek emergency services/response for the client.
EMAIL:
Ensure you have a policy on email communication and that is discussed at the outset of treatment. Ensure you have a signed informed consent document that highlights possible privacy concerns and risks associated with using email. When communicating with patients through email, use encryption.
Be aware that if you are communicating with a patient through his or her work email, it does not have the privacy it would if you are communicating via his or her personal email. A work email is owned by the company, not the patient, and there is no reasonable expectation of privacy. As such, if you end up having a lawsuit or a board issue, even if your care is not at issue, your email communication may not be kept confidential if sent to a work email account.
If you do not check your email outside of work hours or if away, ensure you have an auto-response that reflects this along with what to do in the event of an emergency.
If you engage in text communication with patients, you should first have an office policy concerning when it is appropriate for clients to communicate with you via text and a signed informed consent document that highlights possible privacy concerns when using text messages. It is important to have consistent rules about what types of communications patients are able to communicate with you via text.
Also, you cannot ensure a party other than your client may receive your text. They may leave their phone on the counter, table, or unattended meaning that the text you send may not be received by your client. These risks should be addressed in your informed consent with the client.
Make sure you take a screenshot of any text communication to memorialize in the record. If it becomes apparent that you cannot continue to communicate with your patient via text, for whatever reason, ensure the process for ending such communication is incorporated within your policy, and ensure you memorialize this change by sending a letter to the patient that texting is no longer able to be used.
If an emergency issue arises over texting, be aware of how to seek emergency services/response for the client.
EMAIL:
Ensure you have a policy on email communication and that is discussed at the outset of treatment. Ensure you have a signed informed consent document that highlights possible privacy concerns and risks associated with using email. When communicating with patients through email, use encryption.
Be aware that if you are communicating with a patient through his or her work email, it does not have the privacy it would if you are communicating via his or her personal email. A work email is owned by the company, not the patient, and there is no reasonable expectation of privacy. As such, if you end up having a lawsuit or a board issue, even if your care is not at issue, your email communication may not be kept confidential if sent to a work email account.
If you do not check your email outside of work hours or if away, ensure you have an auto-response that reflects this along with what to do in the event of an emergency.
WHAT DO I PUT FOR THE LOCATION OF A WALKING SESSION?
RESOURCES & REFERENCES
Mental Health and Substance Use Disorder Parity
https://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/mental-health-and-substance-use-disorder-parity
Waldman & Miller (2024).What Mental Health Care Protections Exist in Your State? https://www.propublica.org/article/mental-health-wiltn-states
K. Olvera (2022). Documenting Medical Necessity
https://www.hhs.gov/sites/default/files/hipaa-privacy-rule-and-sharing-info-related-to-mental-health.pdf
Lambert, K JD, MSW, LICSW, CPHRM, FASHRM. The Importance of Documentation in Allied Healthcare. (n.d.). Trust RMS. https://www.trustrms.com/Resources/Articles/the-importance-of-documentation-in-allied-healthcare
Availity Search Tool: You can search here to find insurers and specific plans that verify benefits and process authorization requests and claims electronically through the Availity portal system: https://apps.availity.com/public-web/payerlist-ui/payerlist-ui/#/
https://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/mental-health-and-substance-use-disorder-parity
Waldman & Miller (2024).What Mental Health Care Protections Exist in Your State? https://www.propublica.org/article/mental-health-wiltn-states
K. Olvera (2022). Documenting Medical Necessity
https://www.hhs.gov/sites/default/files/hipaa-privacy-rule-and-sharing-info-related-to-mental-health.pdf
Lambert, K JD, MSW, LICSW, CPHRM, FASHRM. The Importance of Documentation in Allied Healthcare. (n.d.). Trust RMS. https://www.trustrms.com/Resources/Articles/the-importance-of-documentation-in-allied-healthcare
Availity Search Tool: You can search here to find insurers and specific plans that verify benefits and process authorization requests and claims electronically through the Availity portal system: https://apps.availity.com/public-web/payerlist-ui/payerlist-ui/#/