Wiki Medicare psychotherapy documentation

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We have a psychologist whose psychotherapy notes are currently being audited by Medicare, and they are continuously denying them for "Missing/incomplete/invalid plan of treatment." We're having a difficult time figuring out exactly what they are looking for and how to document it. I THINK the biggest problem is that he is not specifying "target dates," since these are patients for whom long-term counseling is the plan, and we don't know how to work around that to their satisfaction. Other than the dates, I am of the opinion that the treatment plans he is documenting are sufficient, though this is NOT my forte and I am uncertain how to guide him. Does anyone have any thoughts or resources on how to document medicare psychotherapy notes to the satisfaction of CMS?
Thank you!
 
There should hopefully be a LCD from the MAC. For instance this an excerpt from LCD [FONT=&quot]L33632 from [/FONT][FONT=&quot]National Government Services, Inc.[/FONT]

Coverage Criteria.[FONT=&quot]The services must meet the following criteria:[/FONT]

Individualized Treatment Plan.[FONT=&quot] The plan must state the type, amount, frequency, and duration of the services to be furnished and indicate the diagnoses and anticipated goals. (A plan is not required if only a few brief services will be furnished.) [/FONT]

Reasonable Expectation of Improvement.[FONT=&quot] Services must be for the purpose of diagnostic study or reasonably be expected to improve the patient's condition. The treatment must, at a minimum, be designed to reduce or control the patient's psychiatric symptoms so as to prevent relapse or hospitalization, [/FONT]and[FONT=&quot] improve or maintain the patient's level of functioning (CMS Publication 100-02, [/FONT]Medicare Benefit Policy Manual[FONT=&quot], Chapter 6, Section 70.1).[/FONT]

It is not necessary that a course of therapy have as its goal restoration of the patient to the level of functioning exhibited prior to the onset of the illness, although this may be appropriate for some patients. For many other psychiatric patients, particularly those with long-term, chronic conditions, control of symptoms and maintenance of a functional level to avoid further deterioration or hospitalization is an acceptable expectation of improvement. "Improvement" in this context is measured by comparing the effect of continuing treatment versus discontinuing it. Where there is a reasonable expectation that if treatment services were withdrawn the patient's condition would deteriorate, relapse further, or require hospitalization, this criterion would be met[FONT=&quot] (CMS Publication 100-02, [/FONT]Medicare Benefit Policy Manual[FONT=&quot], Chapter 6, Section 70.1).[/FONT]

Some patients may undergo a course of treatment which increases their level of functioning, but then reach a point where further significant increase is not expected[FONT=&quot] (CMS Publication 100-02, [/FONT]Medicare Benefit Policy Manual[FONT=&quot], Chapter 6, Section 70.1). When stability can be maintained without further treatment or with less intensive treatment, the psychological services are no longer medically necessary.[/FONT]

Frequency and Duration of Services.[FONT=&quot] There are no specific limits on the length of time that services may be covered. There are many factors that affect the outcome of treatment; among them are the nature of the illness, prior history, the goals of treatment, and the patient's response. As long as the evidence shows that the patient continues to show improvement in accordance with his/her individualized treatment plan, and the frequency of services is within accepted norms of medical practice, coverage may be continued (CMS Publication 100-02, [/FONT]Medicare Benefit Policy Manual[FONT=&quot], Chapter 6, Section 70.1).[/FONT]

[FONT=&quot]When a patient reaches a point in his/her treatment where further improvement does not appear to be indicated and there is no reasonable expectation of improvement, the outpatient psychiatric services are no longer considered reasonable or medically necessary.[/FONT]
 
That is extremely helpful, especially since we also go through NGS. I did not think of checking the LCD - we had been trying to use the ADR they sent us, which was not very clear or helpful. This provides a lot more context to the requirements, since it's the long-term patients we're having the most trouble with. Thank you for getting that to me so quickly!
Christie Anna
 
We found what was missing in our plans was the documentation of frequency and duration in a format that was more clear. An example would be patient will be seen weekly for 6 months. We were lucky enough to have someone from NGS come speak at a seminar we attended so we were able to have a contact. As far as the duration she did specifically say that they understood that depending how the patient was doing the target dates could change. I think anytime you have a patient who is going to be long term due to their diagnosis you need to be very clear as to why it's medically necessary and document in a way that it doesn't sound like a coffee klatch. I think sometimes, especially with long term patient they get comfortable and it's starts to be more social and that is what we want to avoid. I hope that makes sense.
 
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