Document Mental Health Care to Avoid Medicare Denials

Mental Health Care to Avoid Medicare Denials

According to the National Institute of Mental Health (NAMI), 26 percent of all adults experience a diagnosable mental disorder each year, and 6 percent of all adults are faced with a serious mental illness. Fortunately for Medicare beneficiaries, Part A helps covers inpatient mental health care, and Part B helps cover outpatient services, like visits to a clinical psychiatrist, psychologist, or clinical social worker.

Quick Medicare Documentation Tips for Mental Health Professionals

According to the National Association of Social Workers, general documentation guidelines from Medicare Administrative Contractors (MACs) include recording the start and stop time of each session, documenting the patient’s name at the top of each page, ensuring that each entry has a date, and signing all entries in the record with your name, degree, and credentials. You’ll also want to record the type of service provided, such as individual, family, or group therapy. Don’t forget to include the correct CPT® code to identify the procedure, as well as the corresponding ICD-10-CM code for the diagnosis.

You can help forestall failing a Medicare audit by ensuring your documentation includes a diagnostic assessment, treatment plan, progress notes, and a discharge summary or closing report. The diagnostic assessment is essentially an intake note, including the presenting problem, an interval history if appropriate, a mental status examination, and a treatment plan. The treatment plan reviews the methods of improving or resolving problems described in the diagnostic assessment, using objective, measurable goals, and a time frame for meeting those goals. Progress notes are an important part of Medicare documentation, including psychotherapy interventions occurring with each session, including behavioral modification and cognitive behavior techniques. Include dates of future appointments as well as any missed or cancelled appointments. Any care coordination with other healthcare providers, guardians, or caretakers is also recorded here. When Medicare patients receive long-term psychotherapy, consider creating a quarterly summary that documents a review of the goals of therapy, progress as a result of the therapy, and an updated treatment plan. CMS has more tips for Medicare claims success here.

Got Any Tips?

If you’ve had particular success with Medicare mental health claims, we want to hear from you! Share your tips in the comment box below.

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Susan taught health information and healthcare documentation at the community college level for more than 20 years. She has a special love for medical language and terminology. She is passionate about ensuring accurate patient healthcare documentation through education. She has a master's degree in healthcare administration, is a certified healthcare documentation specialist, and serves as immediate past president for the Association for Healthcare Documentation Integrity (AHDI).

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