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Anthony Quintiliani, Ph.D, LADC

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November 18, 2016 By Admin

“Ignorance” of Documentation Requirement Could End Your Clinical Career

“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. rmindfulhappiness_clinicaldocumentationPsychotherapy 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.

  1. Date of service
  2. Correct diagnosis
  3. Duration of service event – start and stop times
  4. Types of therapeutic interventions – all evidenced-based
  5. Target symptoms (assessed via interview, DSM, formal assessment, etc.)americanpsychologicalassociation_mindfulhappiness
  6. Progress in achieving treatment (treatment plan) goals – good progress notes about measured outcomes
  7. Very clear documentation of crisis-oriented services (not specified by this source)
  8. Rational for extended sessions

The CMS Comparative Billing Reports suggests the following additional documentation requirements.

  1. All billed services are medically necessary
  2. No excessive use of psychotherapy code – 45 minute session (or other codes)
  3. Documented client/patient interactions with therapist
  4. Patient/client reaction to the session
  5. Changes is symptoms related to prior session
  6. Changes in behavior related to prior session
  7. 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 psychotherapybusiness_mindfulhappinessNOT 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.

national_psychologist_logo

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, VermontChiYinYang_EleanorRLiebmanCenter

Author of Mindful Happiness  

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Filed Under: ANTHONY QUINTILIANI, Clinical Practice, Featured, Psychotherapy, Regulations & Qualifications Tagged With: AMERICAN PSYCHOLOGICAL ASSOCIATION, CLINICAL, DOCUMENTATION REQUIREMENTS, PSYCHOTHERAPY

June 28, 2016 By Admin

Clinical “Gems” in Psychoanalytic Psychotherapy

 Psychoanalytic Psychotherapy “gems”

In my opinion there are about eleven such “gems” in psychoanalytic psychotherapy.  Use of these interventions in various types of psychotherapy may improve clinical outcomes beyond MINDFUL HAPPINESS_gemsinsight. Although these curative interventions have often been associated with treatment of psychological trauma, object loss, and inner conflict, they may also be useful in the treatment of other clinical conditions: depression, anxiety, eating disorders, and self-medicative addictions.  Along with skilled mindfulness training and practice with a mindfully-experienced therapist, psychoanalytic gems may be helpful to clients suffering from limbic-dominated habit actions, urges and related brain plasticity realities; again, skilled applications of informed mindfulness and yoga, along with the “gems,” may improve the BIG FIVE common co-occurring clinical MINDFUL HAPPINESS_Bigfiveconditions: trauma, addictions, depression, anxiety, and eating disorders. The clinical value of the gems rests in the reality that they may be used in both long-term traditional psychoanalytic psychotherapy AND in short-term interventions within cognitive-behavioral therapy, acceptance and commitment therapy, mindfulness-based cognitive therapy, and mindfulness-based stress reduction. In this first of a series of posts on this topic I will simply list the eleven so-called gems.

In my clinical experience with various forms of psychotherapy and clinical supervision over the past 30 years I have found the following psychoanalytic gems to be very helpful for many of my clients – almost all of whom suffered from complex co-occurring disorders.  What is of more importance is the fact that I never considered myself to be a psychoanalytically-oriented psychotherapist; that approach simply required too long a treatment period to be effective, and it seriously challenged the level of specific cognitive-mental capacities of many of my clients.  I was skilled in various evidence-based therapies, to which I added these “gems.” I did require additional clinical supervision in this advanced integrative therapy process.

Here is my list.

  1. Cultivating the psychoanalytic clinical alliance – the therapeutic relationship
  2. Strategic and limited ab-reaction experiences
  3. Conscious and unconscious linking of childhood wishes into the present relationship
  4. Object and self-object internalization and their presentations in therapy
  5. Re-synthesis of “repressed” failed object relations
  6. Frames of clinical reliability and honest concerns in clinical interactions
  7. Balanced perceptions of self in reality with self and with others – the true and false selves
  8. Corrective emotional experience regarding distorted object representations
  9. Cognitive-behavioral applications of formulated insights – moving the insights into actions
  10. Strategic and limited therapeutic regressions and re-enactments
  11. Uses of conscious projective identification processes (perhaps the most important skills of all)

In the series of posts to follow, I will elaborate the what, how and what-ifs of these “gems.”

By Anthony R. Quintiliani, PhD., LADC

From the Eleanor R. Liebman Center for Secular Meditation in Monkton, VermontChiYinYang_EleanorRLiebmanCenter

Author of Mindful Happiness  

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Filed Under: Clinical Practice, Featured, Psychoanalytical Psychotherapy Tagged With: DR ANTHONY QUINTILIANI, MINDFUL HAPPINESS, PSYCHOANALYTIC, PSYCHOTHERAPY

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