Basics of Documentation for Mental Health Services
Basics of Documentation for Mental Health Services
Medical record documentation is required to record pertinent facts, findings, and observations about a patient’s health history including past and present illnesses, examinations, tests, treatments, and outcomes. The medical record chronologically documents the care of the patient and is an important element contributing to high-quality care. It also facilitates:
- The ability of providers to evaluate and plan the patient’s immediate treatment and monitor his/her health care over time;
- Communication and continuity of care among providers involved in the patient’s care;
- Accurate and timely claims review and payment;
- Appropriate utilization review and quality of care evaluations; and
- Collection of data that may be useful for research and education.
The general principles of medical record documentation for reporting of medical and surgical services for Medicare payments include the following, if applicable to the specific setting/encounter:
- Medical records should be complete and legible;
- Documentation of each patient encounter should include:
- Reason for encounter and relevant history;
- Physical examination findings and prior diagnostic test results;
- Assessment, clinical impression, and diagnosis;
- Plan for care; and
- Date and legible identity of the observer;
- If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred;
- Past and present diagnoses should be accessible for treating and/or consulting physician;
- Appropriate health risk factors should be identified;
- Patient’s progress, response to changes in treatment, and revision of diagnosis should be documented; and
- CPT and ICD-9-CM codes reported on the health insurance claim should be supported by documentation in the medical record.
Maintaining proper documentation for mental health is a challenging task. E2E Medical Billing Services can help you in medical billing and coding services for mental health. You can call us at 888-552-1290 or write to us at info@e2eMedicalBilling.com