10 Commonly Missing Documentation Items in Therapy Notes: A Guide for Insurance Compliance

Admin / September 30, 2023

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When it comes to submitting insurance claims, having proper documentation is crucial. Insurance companies often review treatment plans and progress notes to ensure the services provided align with their requirements. To help therapists and clinicians better navigate insurance compliance, we have identified 10 of the most commonly missed items in charting documentation, along with examples of how to meet the requirements for each.

1. Statement of Progress Towards Specific Goals:
The note should include a clear statement highlighting progress made towards specific treatment plan goals and objectives. For instance, instead of a vague statement like "Tom is making progress towards his goals," provide detailed evidence of progress, such as, "Tom made progress towards his treatment plan goal of managing social anxiety, as shown by two successful public outings where he practiced his new mindfulness and breathing techniques."

2. Location of Service, In-person or Telehealth:
Specify whether the session was conducted in-person or via telehealth. If telehealth was used, mention the usage of a HIPAA-compliant audio/visual platform. For example, "I had a telehealth session with Jane where I was in my private office, and Jane was calling in by herself from her bedroom. We used a HIPAA-compliant audio/visual software [Zoom, doxy.me, SimplePractice, etc.]."

3. Complete Mental Status Exam:
Perform and document a complete mental status examination, including at least three categories such as affect, appearance, behavior, mood, orientation, speech, thought content, and thought process. Provide specific details related to each category to paint a clearer picture. For example, "Aurora's affect was sad and her speech was flattened, but her thought process showed concrete reasoning, and her memory was sound."

4. Description of Symptoms Supporting the Diagnosis:
Include a description of symptoms that directly support the diagnosis. Avoid generic statements and provide specific examples. For instance, instead of stating "Oscar has Generalized Anxiety Disorder," write, "Oscar's diagnosis of Generalized Anxiety Disorder is supported by the following symptoms: he reports feeling irritable, and constantly finds feelings of worry difficult to control..."

5. Person-Centered Details:
Include specific details related to the client's behavior, quotes, and observable actions. This adds depth and context to the documentation. For example, instead of writing "Sarah came into the session. She was sad," write, "Sarah said, 'I feel stressed and sad when I wake up.' She pointed out that her outfit was 3 days old and her hair was disheveled."

6. Recommendation for Follow-up Care:
Clearly state the recommended frequency and level of care for future sessions, especially considering psychiatric diagnostic evaluations. For example, "Having diagnosed Antoine with Major Depressive Disorder, I have recommended he continue to see me every 2 weeks to assess progress on goals and interventions. We plan to discuss a possible referral for medication intervention."

7. Problem Statement Including Diagnosis:
Always include a problem statement that encompasses the initial problem or concern and the official diagnosis. For example, instead of omitting the problem and diagnosis, write, "Alyssa originally sought therapy following frequent panic attacks - at work and often in public. After diagnosing her with Social Anxiety Disorder, we have been considering some interventions to help her manage public settings."

8. Risk Assessment and Safety Plan:
Perform a thorough risk assessment and document any identified risk factors, following up with a corresponding safety plan if necessary. Ensure clear steps are outlined to manage risks. For example, "Tom has acknowledged a temptation to engage in self-harm. As a result, we have worked together on a safety plan to avoid further harmful actions, with the following steps:..."

9. Provider Signature and Credentials:
Sign the therapy note with your provider signature and include your professional credentials. Ensure that this information is clear and visible. For example, "Note signed by provider - /s/ Jane Doe, Licensed Marriage and Family Therapist."

10. Correct CPT Code for Session Time:
Select the appropriate CPT code that matches the duration of the session. Double-check the session length and bill the code accordingly. For example, if the session was 63 minutes long, select and designate the correct time-based CPT code (90837).

Ensuring compliant documentation is crucial for the smooth processing of insurance claims. By addressing the 10 commonly missed items in charting documentation, therapists and clinicians can take proactive measures to meet insurance company requirements. With these guidelines, you can now confidently provide accurate, comprehensive, and compliant therapy notes, improving the efficiency of your billing and claims process.