leadership adders:
STEPS TO A GREAT CAREER IN SOCIAL WORK
documenting for medicare:
tips for clinical social workers
» PURPOSE OF DOCUMENTATION
Medicare uses documentation to:
› Evaluate a clinical social worker’s
ability to plan and assess a
patient’s treatment
› Monitor patient’s care
› Demonstrate communication and
continuity of care among providers
› Assist with accurate and timely claim
review and payment
› Provide appropriate utilization review
and quality care evaluation; and
› Collect data for research and
educational purposes
» GENERAL GUIDELINES
Although a Medicare Adminis
trative
Contractor (MAC) determines
documentation requirements for its
providers, there are general paper and
electronic guidelines required by all
MACs. The general guidelines may
include the following:
› Recording the start and stop time
of each session
› Documenting patient’s name at
the top of each page
› Dating all entries
› Signing all entries in the record
with your name, degree, and other
significant credentials
› Recording the type of procedure
provided such as in
dividual, family,
or group therapy and the appropriate
Current Procedural Terminology (CPT)
code to identify the procedure
› Recording the diagnosis with the
appropriate International
MAY 2012
Medicare requires providers to document all activities and interventions
performed for a Medicare beneficiary. These services include office visits,
telephone calls, consultations, and referrals. Documenting services for a
Medicare beneficiary is an important tool val
idating that services were
performed. It also reveals the ongoing professional activities of a clinical
social worker.
NASW
National Association of Social Workers
750 First Street NE, Suite 700
Washington, DC 20002-4241
Classification of Diseases (ICD) Code
› Documenting an emergency back-up
plan for records when using
electronic tools
» AREAS TO DOCUMENT
To help avoid overpayment requests
and pass a record audit, it is helpful to
document the following areas in a
Medicare record when performing
psychotherapy services:
› A diagnostic assessment
› A treatment plan
› Progress notes
› A closing or discharge summary
» DIAGNOSTIC ASSESSMENT
A diagnostic assessment, also known as
a psychosocial eval
uation, should be
documented in each Medicare record.
The diagnostic assessment assists in
establishing medical necessity and should
reveal evidence that the treatment
services are warranted. Services are
considered medically necessary if they:
› Are proper and needed for diagnosis
and treatment of patient’s mental
health condition
› Are provided for the diagnosis,
direct care, and treatment of
patient’s mental health condition
› Meet the standards of good mental
health practice
› Are not for the convenience of the
patient or the clinical social worker
The diagnostic assessment includes, but is
not limited to, the presenting problem, an
interval history, a mental status
examination, and a treatment plan.
» TREATMENT PLAN
A treatment plan describes how the
patient’s problems identified in the
diagnostic assessment may be improved
or resolved. The treatment plan is
developed to be consistent with the
diagnosis and should contain objec
tive,
measurable goals and a time frame for
obtaining those goals. The patient should
participate in the treatment plan which is
signed by both the clinical social
worker and the patient.
» PROGRESS NOTES
Progress notes are an important and
ongoing part of Medicare documentation
and record psychotherapy interventions
that occur in each session. Progress notes
should reveal the therapeutic interventions
used such as behavior modification,
insight-oriented or c
ognitive behavior
techniques. They also demonstrate the
patient’s response to treatment including
strength, limitations, and progress. Dates
of subsequent, missed, and cancelled
appointments are always recorded.
Coordination of care with the primary
care physician, and other significant
health care providers, guardians, and
caretakers is also recorded.
» QUARTERLY SUMMARY
For long-term Medicare patients receiving
psychotherapy services, it is helpful to
doc
ument a quarterly summary which
includes:
› A review of the goals of therapy
› Progress as a result of therapy
› An updated treatment plan
PSYCHOTHERAPY NOTES
Progress notes that are psychotherapy
notes deserve special attention. For
electronic transactions, HIPAA defines
psychotherapy notes as “notes recorded
by a mental health professional which
document or analyze the contents of a
conversation during a private counseling
session, group, joint, or family counsel
ing
session and are separate from the rest of
the individual’s medical record.” Clinical
social workers and other providers are
exempt from submitting psychotherapy
notes without a patient’s authorization
when the notes in question fit this
definition. Psychotherapy notes exclude
the following:
› Medication and prescription
monitoring
› Counseling session start and stop times
› Types and frequencies of treatment
› Results of clinical tests
Proper
documentation
of a M
edicare
record can help
clinical social
workers to
achieve
successful
Medicare audits
and help avoid
Medicare
overpayment
requests.
› Any summary of patient’s diagnosis,
functional status, treatment plan,
symptoms, and progress to date.
» ERRORS
Existing documentation cannot be
embellished at a later time and should be
corrected as soon as possible. If an error
is made in an electronic record, a dated
addendum should be added to the
record to explain the error and signed.
For paper records, do not erase nor white
out. Instead, draw a single line through
the error, mark it “error,” date and initial
it. If space does n
ot permit, an
addendum may be written to explain the
error. A clinical social worker should be
prepared to explain the error if the record
is audited by Medicare and be aware
of the requirements and special
safeguards required to protect an
electronic health record.
» CLOSING SUMMARY
A closing or discharge summary is
necessary when services are completed
or patient is terminated. It includes a
summary of the problems and treatment
provided including achievement of goal
s,
referrals, and reason for closing or
discharging patient.
Proper documentation of a Medicare
record can help clinical social workers to
achieve successful Medicare audits and
help avoid Medicare overpayment
requests. Important components of a
Medicare record include a diagnostic
assessment, a treatment plan, progress
notes, and a closing or discharge
summary.
RESOURCES
Coleman, M. 2005. Ps ychotherapy Notes
and Reimbursement Claims
.
Washington
DC: NASW Press. Available Online at:
http://socialworkers.org/practice/clinical/
csw0805.pdf
Centers for Medicare and Medicaid
Services. (2005). Psychotherapy notes.
Medlearn Matters [Online]. Available at:
www.cms.gov/Outreach-and-Education/
Medicare-Learning-Network-MLN/MLN
MattersArticles/Downloads/MM3457.pdf
CMS Medicare Claims Processing Manual
(Pub. 100-04). Revised 12/21/11.
Chapter 12 – physicians/non- physician
practitioners . Section 170. Was
hington DC:
Government Printing Office.
NASW. (2002). Documenting patient care
in the private practice setting. SPS Practice
Update
.
Washington, DC: NASW Press.
©2012 National Association of Social Workers. All Rights Reserved.
