The Shadow Side of Therapy: Audits, Insurance Coverage, Documentation, and Medical Necessity

• Identify 3 ways that notes that are vague, illegible, or written long after the session can harm therapists and clients
• Identify 5 common health plan documentation requirements
• Identify 2 additional items that may be legally required in telehealth session documentation
• Define the components of “medical necessity criteria” used by health plans to approve ongoing treatment, and give an example of how to document this
• Identify the components of a treatment plan, and define “SMART goals”

• Why We Don’t Keep Better Progress Notes — And Why We Should
• HIPAA: Progress vs. Psychotherapy notes
• What Should be in Your Intake Notes: 11 Common Health Plan Requirements
• What Should be in Your Progress Notes: 11 Common Health Plan Requirements
• Telehealth Documentation: Legal and Ethical Best Practices
• Understanding and Documenting Medical Necessity
• Analysis of a Sample Progress Note
• Why Your Notes Might be Requested-by a Health Plan- And How to Respond
• Insurance Fraud and Altering Notes
• Treatment Plans: What Should be in Them, Choosing Appropriate Goals, and Updating Them
• Audits: Why Your Records Might be Requested, How to Respond, and How to Reduce Your Risk
• Ethical Insurance Billing For Telehealth — Current Codes and Coverage issues

American Medical Association, CPT® 2019 Standard Edition.  Chicago, IL; American Medical Association, 2018.

OPTUM 360 (2018).  Current Procedural Coding Expert.

APA Office of Health Care Financing.  (2016, November 16).  Psychotherapy coding clarifications, telemedicine code modifier added to CPT manual.  Retrieved March 20, 2018, from http://www.apapracticecentral.org/update/2016/11-17/telemedicine-code.aspx

OPTUM by United Behavioral Health. (2014, February), Coverage Determination Guidelines, Extended Outpatient Sessions, Retrieved March 20, 2018, from https://providerexpress.com/trans/html/pdf/extendedOutpatientVisits.pdf

Dustman, R. (2016, February 16).  Prolonged Services Update and Other 2016 E/M Changes.  Retrieved March 20, 2018, from https://www.aapc.com/blog/33732-prolonged-services-updates-and-other-2016-3m-changes/

Specific criteria must be met to use prolonged services code.  American Academy of Pediatrics News (January 10, 2018); Retrieved Feb 10, 2019 from http://www.aappublications.org/news/2018/01/10/Coding010518

American Academy of Child and Adolescent Psychiatry. (2018)  CPT Training Manual. Retrieved Feb 11, 2019 at https://www.aacap.org/App_Themes/AACAP/docs/clinical_practice_center/business_of_practice/cpt/2018_CPT_module_revised_March_2018.pdf

Direct Prolonged Serices: Inpatient and Outpatient Coding.  American Academy of Pediatrics (2016). Retrieved Feb 11, 2019 at https://www.aap.org/en-us/Documents/coding_prolonged_services.pdf

The 2013 Psychotherapy Codes: An Overview for Psychologists. (n.d.). Retrieved March 20, 2018, from http://www.apapracticecentral.org/reimbursement/billing/psychotherapy-codes.aspx