Brenda1973
Networker
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Where can I find the required documentation that needs to be included on the LCSW progress note template for Behavioral Health?
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Wiki BH Progress Note Template
- Thread starter Brenda1973
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Best practice is SOAP notes. It also depends on what payers the LCSW will be billing, since CMS is usually the strickest, I would start there. I found this language on the last page of the CMS document below in the link that I shared, I searched on Google "CMS Psychotherapy Documentation Requirements" Also know that you will have to tie the services rendered to the treatment plan.
"C. Psychotherapy Notes Psychotherapy notes are defined in 45 CFR §164.501as “notes recorded by a mental health professional which document or analyze the contents of a counseling session and that are separated from the rest of a medical record.” The definition of psychotherapy notes expressly excludes medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of diagnosis, functional status, treatment plan, symptoms, prognosis, progress, and progress to date. Physically integrating information excluded from the definition of psychotherapy notes and protected information into one document or record does not transform the non-protected information into protected psychotherapy notes. Under no circumstances shall a contractor request a provider to submit notes defined in 45 CFR §164.501. The refusal of a provider to submit such information shall not result in the denial of a claim. If the medical record includes any of the information excluded from the definition of psychotherapy notes in §164.501, as stated above, the provider is responsible for extracting the information required to support that the claim is reasonable and necessary. Contractors must review the claim using all supporting documentation submitted by the provider. If the provider does not submit sufficient information to demonstrate that services were medically necessary, the claim will be denied. "
Link to CMS
Psychotherapy Notes
Hope this helps!
"C. Psychotherapy Notes Psychotherapy notes are defined in 45 CFR §164.501as “notes recorded by a mental health professional which document or analyze the contents of a counseling session and that are separated from the rest of a medical record.” The definition of psychotherapy notes expressly excludes medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of diagnosis, functional status, treatment plan, symptoms, prognosis, progress, and progress to date. Physically integrating information excluded from the definition of psychotherapy notes and protected information into one document or record does not transform the non-protected information into protected psychotherapy notes. Under no circumstances shall a contractor request a provider to submit notes defined in 45 CFR §164.501. The refusal of a provider to submit such information shall not result in the denial of a claim. If the medical record includes any of the information excluded from the definition of psychotherapy notes in §164.501, as stated above, the provider is responsible for extracting the information required to support that the claim is reasonable and necessary. Contractors must review the claim using all supporting documentation submitted by the provider. If the provider does not submit sufficient information to demonstrate that services were medically necessary, the claim will be denied. "
Link to CMS
Psychotherapy Notes
Hope this helps!
ElleK
Contributor
Hello, I am a Medical Coder and Compliance Specialist at my place of employment.
Here are the requirements I have put fourth to by providers and billing team. I hope this helps
Here are the requirements I have put fourth to by providers and billing team. I hope this helps
- Chief Complaint – Must be a direct quote from the patient. “Follow-up” or “need meds” is insufficient.
- Date of Service
- Patient Location – In-office or telehealth. Telehealth must be specified (home, other)
- Visit Type – Initial visit or follow-up
- History of Present Illness – HPI (psychiatry)
- Past, Family, and Social History (must be included with initial assessment)
- Procedure Documentation - CPT codes being billed must be included here. Description of services rendered – does it support the CPT codes used. CPT codes should be accurate based on Medical Decision Making and Time-Based Supportive Therapy
- Appointment Time – Psychiatry services require both the appointment time, and the actual time spent providing supportive therapy
- Diagnostic Tests and Results – Mental Status Exam, assessments, (CFAR/FAR)
- Diagnosis – Listed with appropriate ICD-10-CM diagnosis code(s)
- Treatment Plan – Must be measurable and obtainable goals with progress documentation.
- Prescribed Medication (psychiatry) – Type, dosage, patient must agree
- Referrals (if applicable)
- Follow-up Recommendations – List follow-up appointment or other services
- Summary of Session (progress report) – A detailed description of the visit; why the patient presents for services, how the patient presents, (tone, appearance, expressions) discuss interventions and techniques used, notate progress, etc.
- Signed Off Correctly – Must be signed off by a par provider within 3 days