“Ignorance” of Requirements Could End Your Clinical Career
Recently various insurance, Medicaid, and Medicare fraud cases have been in the national headlines. Although these fraud cases grab headlines, the truth is that many clinically licensed helpers still do not understand clinical/legal documentation requirements. In Buddhism, “ignorance” gets in our way; we never approach true liberation via enlightenment. Practice takes years and years to produce experienced movement from samsara to liberation. Sometimes our progress is very subtle. In clinical practice “ignorance” gets in our way; it takes years and years to become educated and clinically licensed – all of which may be lost if we appear to practice in fraudulent ways. All those years of learning; all those years of supervised practice; all your own costs to be where you are; and, all those years of billing for our sacred services. Yes, your services are sacred in that they reduce human suffering, and may sometimes bring happiness to people. 
Psychotherapy SAVES LIVES!
In audit terms, there are three enemies of clinically appropriate documentation: fraud, waste and/or abuse. I will not make clarifications about these three situations in this post. The standard definition of fraud notes that it involves the clinician receiving something of value via willful misrepresentation. In this post I will simply notes a couple well-known lists of clinical documentation requirements. I am always amazed how graduate training programs and professional associations have not been consistent in how they inform “psychotherapists” about documentation requirements. The main pathway to successful employment is effective clinical skill (alliance and outcomes); the major pathway to getting paid for that good work and staying out of court is following published documentation requirements. One of the major problems with documentation requirements is that they change based on the system paying for the sessions. Another problem is that any system’s requirements may change without prior notice to providers of clinical services. Clinicians need to pay attention to what their payments require, both in coding changes and in documentation changes.
The American Psychological Association has recommended the following minimum documentation requirements for clinical records per session.
- Date of service
- Correct diagnosis
- Duration of service event – start and stop times
- Types of therapeutic interventions – all evidenced-based
- Target symptoms (assessed via interview, DSM, formal assessment, etc.)
- Progress in achieving treatment (treatment plan) goals – good progress notes about measured outcomes
- Very clear documentation of crisis-oriented services (not specified by this source)
- Rational for extended sessions
The CMS Comparative Billing Reports suggests the following additional documentation requirements.
- All billed services are medically necessary
- No excessive use of psychotherapy code – 45 minute session (or other codes)
- Documented client/patient interactions with therapist
- Patient/client reaction to the session
- Changes is symptoms related to prior session
- Changes in behavior related to prior session
- Very clear documentation of crisis oriented services (not specified by this source)
Disclaimer – I provide this information as it has been provided to me. I cannot say if it is totally accurate. You are responsible for checking into your own documentation requirements based on what systems pay you for your clinical services. It is so, so sad that such sacred work requires accounting-like documentation. I have often commented that psychotherapy records mimic documentation for transporting nuclear waste actress state lines. So much documentation; so little time to actually DO the psychotherapy. Hope this post shakes you up a bit regarding your current clinical documentation habits.
How did we get into such a bureaucratic way of doing business? Well, that is it – psychotherapy is now a business. Perhaps our very generous payments to medical staff caused this (other than primary care American medical doctors are some of the world’s highest paid professionals providing such services). When therapists decided to make a living from doing psychotherapy, and when many university programs opened graduate training programs for psychotherapists, education, business and “organic bureaucracy” (my terms) became ONE. Following the old “medical model,” psychotherapy became a way to earn a middle class living, sometimes a very good middle class living. Behavioral health, however, will never be funded at levels needed to improve the mental health (and addictions health) of the American public. Pills alone will 
NOT DO IT! Our problems are NOT simply biological; they are biopsychosocial-spiritual in nature. How else could we be about 5% of the world’s population consuming about 60-70% of the world’s illicit drug? Are we empty inside? Let’s hope that psychotherapy does not follow
medical practice in hospitals, where well-documented data show that about 100,000 people a year die due to medical errors. Some researchers believe that number is actually higher. Powerful lobbying groups hope to influence the federal government so such data will not be available to the American people. And, there are the added burdens of requiring external “certification” of your program’s comparative quality. The various “commissions” that dictate documentation requirements in behavioral and medical health care systems ADD MORE AND MORE DOCUMENTATION REQUIREMENTS AT HUGE COSTS. As if documentation alone implies quality. Let’s get rid of the onerous documentation requirements and simplify the system; let’s pay for carefully rationalized clinical outcomes and end the dollar drain of accreditation commission-dictated documentation requirements. Such a rational shift may cause an unemployment crisis in bureaucracy, but it may help preserve the slim margins of funding in behavioral health. The American health care system needs BIG changes, but we lack insightful and courageous leadership to make such big changes. What will the future of behavioral health look like? Better start lobbying for your own interests before you have no profession to lobby for at all.
For more information refer to your own payment systems, Medicaid, Medicare, private insurance and other documentation requirements. See also Hartman-Srien, P. E. (November-December, 2016). Fraud grabs headlines… The National Psychologist, p. 6.
By Anthony R. Quintiliani, PhD., LADC
From the Eleanor R. Liebman Center for Secular Meditation in Monkton, Vermont
Author of Mindful Happiness
Common and effective approaches using mindfulness-based interventions, skills and practices include Mindfulness-Based Stress Reduction (MBSR via Jon Kabat-Zinn), Mindfulness-Based Cognitive Therapy (MBCT via Zindel Segal, Mark Williams, and John Teasdale), Acceptance and Commitment Therapy (ACT via Steven Hayes), and Breathwork Mindfulness-Based Approaches to Pain and Illness (MBPI via Vidyamala Burch). There are other mindfulness-based approaches; however, the first three noted and their integration in MBPI have received a greater level of research support in recent years.
