Mental Health Documentation and Medical Necessity: Simple, Clear Guidelines that Maintain Quality of Care and Protect Your Practice – Beth Rontal, MSW, LICSW

Salepage link: At HERE. Archive:

“I love paperwork!”.

–Said NO clinician, EVER

Yet, the success of your practice depends on your ability to write good intake summaries, treatment plans, session notes, case/collateral notes, and discharge summaries. Taken together, these pieces to the documentation puzzle support your goal of providing quality services to your clients. They also impact the stability and success of your practice. When done well, they result in piece of mind and timely payment from insurance companies. When done poorly, they lead to the misery of denials, audits, and lost income.

The great news is that you CAN become proficient at mental health documentation and medical necessity. This seminar provides clear and simple guidelines for recordkeeping that adheres to professional standards and ethical codes, supports delivery of quality care, and reduces errors and delays in payments.

You will receive expert instruction from Beth Rontal, LICSW, affectionally known as the Documentation Wizard. For over 15 years, Beth has been instrumental at changing how individuals and organizations approach documentation. The results speak for themselves. Rates at which paperwork was returned to clinicians for correction have dropped significantly, in one case from 65% to under 8%. This gave clinicians back 3 to 5 clinical hours per week, saving thousands of dollars and improving job satisfaction.

1. Determine the importance of proper documentation in informing clinical decision-making.
2. Evaluate the role of the clinical diagnosis in justifying medical necessity and providing more effective services to clients.
3. Determine how to use the behavioral language required by insurance companies to facilitate delivery of services to clients.
4. Assess how to document what really happens in a clinical session without violating privacy or confidentiality.
5. Assess medical necessity by employing the “golden thread” for improved treatment outcomes.
6. Analyze potential red flags in documentation and the proper corrective measures for them

Get Past Your Negative Feelings About Documentation

• Documentation as a contributor to good clinical work
• Documentation through the lens of the “Golden Thread”
• Documentation as a protector of income and integrity
• Anxiety-reducing answers to common questions

Embrace the Requirement of Medical Necessity

• The elements of medical necessity
• The “Golden Thread” as a key part of medical necessity
• Establish the connection between diagnosis and treatment

How to Write:

• The Diagnostic Summary
  • What’s needed in the diagnostic summary, and why
  • How the diagnostic summary initiates the path of the Golden Thread
• The Treatment Plan
  • What’s needed in a treatment plan, and why
  • Operationalize the presenting problem
    • Questions to ask
    • Describe the diagnostic criteria in behavioral terms
  • Make a clear connection between goals, objectives, and interventions
  • Protect the client and the therapist with a thoughtful risk assessment
  • Evaluate client progress
  • How the treatment plan it continues the path of the Golden Thread
  • And more …
  • Activity: Write a treatment plan
• The Session Note
  • The session’s note relationship to the treatment plan
  • What’s needed in a session note and why
  • Descriptive or narrative approach to interventions used
  • Changes to treatment plan
  • Justify multiple sessions
  • Activity: Write a session note
• The Case and Collateral Contact Note
  • What’s needed in a case and collateral contact note and why
  • Differences between case and collateral contact notes
  • Provide a clinical justification for the case/collateral consult
• The Discharge Summary
  • What’s needed in a discharge summary, and why
  • How the discharge summary completes the Golden Thread

20 DOCUMENTATION RED FLAGS THAT LEAD TO TROUBLE