Psychiatry and Psychology Services
CERT has determined that insufficient documentation caused improper payments for psychiatry and psychotherapy; insufficient documentation means that information was missing from the medical records. Information frequently missing were:
- Initial evaluation: Psychiatric diagnostic evaluation is an integrated psychosocial assessment, including history, mental status and recommendations. The evaluation may include communication with family or other sources and review and ordering of diagnostic tests.
- Individualized treatment plan: The plan must state the type, amount, frequency, and duration of the services to be furnished and indicate the diagnoses and anticipated goals. (A plan is not required if only a few brief services will be furnished.)
- Updated treatment plan: An updated treatment plan must be included in the medical record which includes a periodic summary of goals and progress toward goals. Prolonged periods of psychotherapy must be well-supported in the medical record describing the necessity for ongoing treatment.
- Time (length of session): The medical record must indicate the time spent in the psychotherapy encounter with the patient. The total time can be noted or the time in and time out.
- Signature (of the performing provider): An electronic signature or legible signature is required on all notes.
Related Content
- NGS Medical Policies
- LCD for Psychiatry and Psychology Services (L33632)
- CMS IOM Publications:
- 100-02, Medicare Benefit Policy Manual, Chapter 6, Section 70.1 (217 KB) (Outpatient Hospital Psychiatric Services)
- 100-04, Medicare Claims Processing Manual, Chapter 1, Section110 (1.7 MB) (Insufficient Documentation)
- 100-08, Medicare Program Integrity Manual, Chapter 3, Section3.3.2.6 (641 KB) (Psychotherapy Notes)
- 100-08, Medicare Program Integrity Manual, Chapter 3, Section3.3.2.1 (641 KB) (Signature Requirements)