Psychotherapy Services Decision Tree
This set of questions will assist with review of Documentation requirements for Psychotherapy services:
1. Is the provider an MD, DO, NP, PA, CCNS, Clinical Psychologist or Clinical Social Worker?
2. Is the diagnosis codes F72, F73, F78, or F79-Severe and profound mental retardation?
Yes No
3. Does the documentation support the visit was only performed for monitoring of Activity of Daily Living (ADL); teaching grooming skills or teaching social skills?
Yes No
4. Are ALL the following present in the documentation for the individualized treatment plan: type, amount, frequency, duration, diagnosis, anticipated goals?
Yes No
5. Does the clinical note support a face to face visit with the patient present and participating?
Yes No
6. Does the clinical note support the diagnosis, symptoms, functional status, mental status exam, treatment plan, prognosis and progress of the patient?
Yes No
7. Does the documentation support therapeutic maneuvers; communication attempts supportive or interpretive interactions to produce a therapeutic change?
Yes No
8. Is there a periodic summary of goals, progress toward goals, and an updated treatment plan included in the medical record?
Yes No
Prolonged periods of psychotherapy must be well-supported in the medical record describing the necessity for ongoing treatment.
9. Is there reasonable expectation of improvement or reasonable expectation that if treatment services were withdrawn, the patient’s condition would deteriorate?
Yes No
Prolonged periods of psychotherapy must be well-supported in the medical record describing the necessity for ongoing treatment.
10. Frequency/Duration: Does the evidence show that the patient continues to show improvement in accordance with the treatment plan? Is the frequency within accepted norms of medical practice?
Yes No
Prolonged periods of psychotherapy must be well-supported in the medical record describing the necessity for ongoing treatment.
11. Does the documentation contain the time for the service performed and support the level of service billed?
Yes No
Correct Time and coding: Service allowed based on documented time
- 16-37 minutes 90832
- 38-52 minutes, 90834
- 53 or more for 90837
12. Does all documentation meet signature requirements and include the name, signature and credentials of the person performing the service?
Yes No
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