Article - Billing and Coding: Psychiatry and Psychology Services (A56937)

 One portion of the note that is common to all patients, documenting date, length of time for the session, along with key issues presented. Names of the patients in the group should not appear in this group note. A second portion of the note, for each patient's record, commenting on that particular patient's participation in the group process and any significant changes in patient status. As outlined in HIPAA regulations referenced above, the note should exclude sensitive content of the patients' conversation.While there are no specific limitations on thefrequency or length of time that outpatient psychiatric servicesmay be covered, there are many factors, including the nature of the illness, prior history, goals of treatment, and the patients response, that affect the outcome of treatment. When outpatient psychiatric services are provided at a high frequency or long duration, the plan of treatment, progress notes, and condition of the patient should justify the intensity of the services rendered.Forpsychotherapy services, there should be documentation of the patient's capacity to participate in and benefit from psychotherapy, especially if the patient is in any way cognitively impaired. The medical record should document the target symptoms, goals of therapy and methods of monitoring outcome. There should be documentation in the medical record of how the treatment is expected to improve the health status or function of the patient.Those hospitals that provide services atoff-campus locationsmust clearly document in the medical record the location of the billed services, and that the services were properly supervised.The medical record must reflect the elements outlined in thePsychiatric Diagnostic Proceduresdescription and must be rendered by a qualified provider (see "Limitations" in related LCD).The medical record must reflect the elements outlined in the aboveInteractive Complexitydescription and must be rendered by a qualified provider (see "Limitations" subsection in related LCD). Additionally, the medical record must include adaptations utilized in the session and the rationale for employing these interactive techniques. The medical record must include treatment recommendations.The medical record must indicate the time spent in thepsychotherapyencounter and the therapeutic maneuvers, such as behavior modification, supportive or interpretive interactions that were applied to produce a therapeutic change.Behavior modificationis not a separate service, but is an adjunctive measure in psychotherapy. Additionally, a periodic summary of goals, progress toward goals, and an updated treatment plan must be included in the medical record. Prolonged periods of psychotherapy must be well-supported in the medical record describing the necessity for ongoing treatment.The medical record must document the indications forpsychoanalysis, description of the transference, and the psychoanalytic techniques used.The medical record must document the conditions described under thepsychoanalysis, group psychotherapy, family psychotherapy, and/or interactive group psychotherapy"Description" and "Comments" sections in related LCD relative to codes 90846, 90847, and 90849.The medical record should document the medical necessity ofnarcosynthesis for psychiatric diagnostic and/or therapeutic purposes(e.g., the patient had difficulty verbalizing their psychiatric problems without the aid of the drug). The record should also document the specific pharmacological agent, dosage administered, and whether the technique was effective or non-effective.The record must indicate that thePsychotherapy in Crisisguidelines under the "Description" and "Comments" sections in the related LCD were followed.Claims for90880must be submitted with a covered diagnosis.The medical record must indicate the presence of mental illness or signs of mental illness for whichpsychological testingis indicated as an aid in the diagnosis and therapeutic planning. The record must show the tests performed, scoring and interpretation, as well as the time involved.The medical record must document that theCentral Nervous System Assessments/Testsguidelines outlined in the "Description" and "Comments" sections in the related LCD were followed.