| Providers in AR, CO, LA, MS, NM, OK, TX, Indian Health & Veteran Affairs | |
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This checklist is intended to provide healthcare providers with a reference for use when responding to medical documentation requests for psychotherapy services. Healthcare providers retain responsibility to submit complete and accurate documentation.
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Documentation description |
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Documentation is for the correct beneficiary. |
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Documentation contains a valid and legible signature. |
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Documentation clearly identifies the person performing the service (including title, education background, credentials). |
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Documentation clearly demonstrates session start and stop times and/or total time spent providing psychotherapy services to the beneficiary. |
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Documentation demonstrates the telehealth method utilized during the service (i.e., audio/video), if applicable. |
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Documentation demonstrates the type of service being provided (including the therapeutic techniques and approaches including modalities and frequencies of treatment furnished). |
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Documentation supports the medical necessity for psychotherapy treatment as evidenced by: The maladaptive behavior that supports the need for ongoing psychotherapy treatment. Results of clinical tests performed. Medication prescription and monitoring (if applicable). Summary of the diagnosis/symptoms, functional status, and treatment plan. Frequency of treatment furnished, prognosis, and progress. |
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Documentation to support "incident to" guidelines (if applicable), that includes evidence of billing provider's presence in the office suite and ongoing participation in patient care. |
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For services that include an E/M component, the E/M services should be documented. |
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If applicable and required, submitted documentation should include a beneficiary waiver of liability. | This checklist was created as an aid to assist providers. This aid is not intended as a replacement for the documentation requirements published in national or local coverage determinations, or CMS documentation guidelines. It is the responsibility of the provider of services to ensure the correct, complete, and thorough submission of documentation.
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