Documentation Rubric

Watch the video below on payble documemntation requirements and how to use the clarity docuemntation rubric. 

Documentation Templates

For your convenience we have provided documentation templates for a few common diagnoses. 

Documentation FAQs

 A word about Generalized Anxiety Disorder (GAD)

Many therapists over diagnose GAD. Caution, this may be your diagnostic bias. 

Facts: 40% of individuals with GAD end up on disability, GAD is synonymous with severe role impairment across domains. Impairment is the differential diagnosis between GAD, Adjustment w Anxiety or even Unspecified Anxiety, Disorder or Other Specified Anxiety Disorder. 

According to current meta analysis the lifetime prevalence of GAD from ages 18-64 is 6.2% of the clinical population. If your caseload does not reflect that data point, please check and be able to defend your differentials to remain compliant.

Q) When is documentation due? 

A) Documentation is due 48 hours from time of appointment- it must be signed and lock to be considered completed. This helps us meet best practice standards and get  claims submitted and you paid in a timely manner. To meet best practice standards claims are not filed until documentation is complete.

B) All edits requested on documentation during your note reviews are also due within 48 hours of edit request. 

Q) Which documentation format do I use? 

A) Intakes most clinicians use the Intake note template in SP.

For ease of use, our client intake questionnaire is designed to follow along with the questions in the biopsychosocial note template. Most clinicians use the rubric templates in SP.

Q) Should I type/take note on my laptop during the intake?

A) No. Unless you are a multi-tasking whiz and have mastered the art of being in two places at once, DON'T. This kills connection, makes client think they are in another medical appointment where their provider is not listening to them. 

If you need to refer to your laptop during the assessment, go for it! Otherwise, use a good ol' paper and pen and jot down the important stuff (i.e. diagnosistic criteria and risk assessment). All of the other info can come later. Making a connection and building rapport is the *most* important part of that initial intake session. Don't let technology ruin that. 

Q) Which CPT codes should I use?

A) Therapists are responsible for understanding and choosing accurate CPT codes. Therapists are also responsible for changing CPT codes in real time in SP. Documentation should reflect the chosen CPT code. 

See CPT guidelines above- it's important these are correct they can lead to insurance fraud in an audit and extra time consuming billing and administrative work 

Q) What are the insurance company requirements?

A) It is the responsibility of the clinician to obtain that knowledge and practice according to insurance and their board's guidelines. 

Documentation must Include:

• Diagnosis

  • DSM Criteria: each criteria must be met- Duration Criteria: Duration criteria is most overlooked. How the client’s symptoms meet the duration criteria/that the client still meets criteria should be made clear in every note.

  • Must show medical necessity and need for ongoing treatment

  • Must match treatment rendered. Do not implement relaxation strategies for someone who is depressed and lethargic. 

  • Know You Diagnostic Bias - Know your differentials and clinical prevalences. Disproportionate diagnosing can trigger an audit. For example, 40% of a clinician's caseload is diagnosed with GAD but according to the DSMV GAD occurs in approximately 6% of the clinical population. That indicates a diagnostic bias unless otherwise justified. Can you defend your differential? Are you missing something? 

  • Frequency- difference between ADHD and no diagnosis.

  • Intensity- difference between ODD and Conduct Disorder.

  • Duration- difference between mania and hypomania.

  • Onset- difference between Acute Stress Disorder and PTSD.

•  Treatment Rendered/ Interventions- what you did to treat the specific dx you made that session. ex. CBT for ED, Depression, or Anxiety, etc. Must show its relevance to your diagnosis to be reimbursed for services.

• Document dose of treatment recommended and any changes. One hour, once a week is a widely accepted treatment and researched backed treatment dose. If you choose to see a client more frequently or for longer or shorter sessions you’d document your clinical rationale to show how it is indicated for this client’s treatment to prove medical necessity.

  • Insurance companies look critically for medical necessity- the justified NEED for ongoing treatment. 

  • Clients seen at a higher frequency than a typical dose (once a week) medical necessity must be justified. Ex, Cl seen twice a week vs once a week. They are looking for high severity, risk of inpatient etc. to meet medical necessity.

• Your clients progress toward goals, response to interventions using symptoms tied back to the diagnosis. 

• Risk assessment and safety plan - when indicated.

• Coordinated Care/Referrals/ Medications

• Name your source accurately: Specify where your diagnostic information is came from. Is it an assessment, a measure, client self report, therapist observation, etc? The phrase “Cl reports…” is often used to specify. “Cl reports bio monther has bipolar disorder...” rather than “Bio mother has bipolar disorder...”. Unless you have assessed or tested bio mother yourself. “Cl reports previous dx of…” Vs. “Cl was previously diagnosed with…”.

• Concise intentional note taking - Writing too Much is the number one mistake providers make. Know your audience. Who are you writing for? Other providers? Insurance? Your client? Consider your client ordering their records or them falling into the wrong hands. A good rule of thumb that anything that is not directly pertaining to your diagnosis or medical necessity belongs in psychotherapy notes/process notes. 

• Long documentation communicates to your audience that you don't know precisely what you should document, other providers do not read long notes. It is unethical to include extraneous client information, and it’s more difficult for auditors to find the information they need.

Q) What are Clarity note audits?

A)  Note audits are part of your KPIs and how you know you're doing the practice a solid by writing payable compliant documentation. Clarity preforms frequent note audits to provide feedback so our providers can continuously refine their skills and remain compliant. Therapists scoring well are no longer audited. Ultimately, it is the therapist's obligation to complete compliant payable documentation- we do audits to help you.

Q) Do you have an intake template?

A) We do not have a example template but we do have a documentation format in SP. 

Q) Do I need to create a treatment plan?

A) Treatment plans are not a requirement of our contracted insurance companies but you are welcome to. If you do create a treatment plan your progress notes should accurately reference it and it should be reviewed and updated on a regular basis.  

Q) A client from my previous workplace followed me to Clarity and is being seen for the first time? How do I code that session? 

A) Unless there is clinical reason (should be documented in your notes) insurance usually approves one 90791 per year. The client should complete all of the usual new client clarity paperwork. If you need more information supervision or consulting can be helpful.

Q) My client can only come every other week or once a month but I'm aware the recommended treatment dose for all new clients is once a week. How do I document that?

A) Insurance documentation criteria includes documenting changes or variation in treatment dose. Requiring a practitioner to notate any change from the recommend treatment dose and why those changes occurred (ie. twice a week, every other week, once a month, etc.). It is recommended to document that best practice treatment dose and your recommendation was reviewed with client. As well as any reason for variation from recommended treatment dose. 

Q) My client asked to be/needs to be seen twice a week, what should I do?

A)  Payors will only cover it if medical necessity is met, see below for insurance medical necessity criteria. In order to be compliant with insurance it must be indicated in ongoing documentation why the client should be seen twice a week- i.e. show medical necessity. If they deem it not to meet medical necessity insurance will not pay for that visit or ask for money back in an audit.

If the client is self pay, the issue is clinical (ethical obligation to nonmaleficence and beneficence). Is twice a week indicated or will I be sending a message to this client that they are sicker than they really are? For more on the clinical side of this topic please seek out supervision. 

BCBS Medical Necessity:

Frequency Criteria: for treatment that occurs more frequently than once per week (excluding Medication Management) must have all of the following (1 - 3) to qualify:

1. Either the Covered Individual has been discharged from an inpatient, residential or partial hospitalization program (PHP) service and more frequent outpatient (OP) treatment is required as a transition for the purposes of stabilization while returning to the community or the Covered Individual is in crisis as evidenced by suicidal ideation or high risk behavior that is manageable on an OP basis, or an unexpected increase in symptoms and/or behaviors or worsening in mood where the treatment goals are focused on stabilization of the crisis; AND

2. The symptoms/behaviors or mood that represent the crisis can be stabilized with more frequent treatment as evidenced by urgent psychiatric contact and medication changes if indicated and reports of progress with resolving the crisis; AND

3. The condition has not stabilized to the point where less frequent treatment which targets less critical symptoms/behaviors is equally appropriate.

Q) What is the onboarding note review process like? 

A) BCBS allows providers to bill during the time they’re being added to our group. They deem someone with equal or higher degree who is currently paneled as your “on site supervisor”. That 'supervisor' is required to review and sign your notes until you are paneled. The administrative process is detailed below.

• Complete documentation according to contract specified timeline. Share with onsite supervisor. There is a process in SP to share your notes. See Simple Practice Page for details. 

• We’ll review and supervisor will give feedback. Typically, the same week. “Do they meet insurance and best practice guidelines? Will they pass an audit?”

• After feedback, you’ll make edits and re-share with supervisor for their signature. 

• When the note has both the supervise's and supervisor's signature, the note is completed.

• Please make revisions and re-share within 48 hours in order to ensure documentation is completed in a timely manner. 

 Q) How do I share notes with my on site supervisor in Simple Practice?

A) Check out the Simple Practice Page for links.