Misery or Mastery
Documenting Medical Necessity
- Reduce Anxiety
- Maintain Professional Integrity
- Protect Income
Misery or Mastery TM: Documenting Medical Necessity for Psychotherapists
Kaua'i Workshop is almost full! Enroll now to reserve your spot!
Honolulu workshop has been canceled due to lack of enrollment.
DATE/TIME: May 31, 2019, 9:30 AM – 5 PM
LOCATION: Kaua'i, Hawai'i
Hilton Garden Inn Kauai Wailua Bay
3-5920 Kuhio Highway
Kapaa, Hawaii, 96746
CONTINUING EDUCATION HOURS: 6
LUNCH: not included
Clinical Documentation has always been integral to the professional standard of care. Yet many psychotherapists are unsure how to document the good work they provide. As a result, they can feel at the mercy of insurance companies, spending an enormous amount of time justifying treatment, fighting rejected insurance claims, fearing or preparing for audits, writing disability reports and losing income. Clinicians both in private practice and those working in agencies and group practices, as well as clinic owners and managers report there is little guidance about what to write while clinicians find that there is little time to write it. Paperwork often seems unrelated to being helpful to the client. Confusion over third-party expectations and often substandard paperwork is a common result, leaving both clinician and clinic vulnerable to a financial loss if records are audited, or to legal, ethical or professional issues if records are subpoenaed.
With the growing concerns about addiction, child safety, family violence, legal issues, and the corresponding rise in oversight, whether from insurance companies, the department of social services, workman’s compensation, or the courts, the more important good record keeping has become. Additionally, because the courts can mandate access to records, understanding issues of confidentiality and privacy in relationship to documentation requirements are critical.
Good documentation skills should help organize clinical thinking. Progress notes, treatment plans, case and collateral contact notes, discharge and diagnostic summaries should be able to be done quickly and efficiently and provide a vehicle for formulating and reflecting on high quality clinical work rather than being a detour or afterthought. Good documentation supports good clinical practice, facilitates getting authorizations, and helps mental health professionals and clinics pass insurance audits, thus saving thousands of dollars in potential recoupments and lost productivity. It contributes to a marked reduction in work related anxiety and increased job satisfaction.
Since psychotherapy is covered by medical insurance, the gold standard for documentation is now based on the need to satisfy insurance company requirements. The most rigorous standards for clinical documentation are Federal, which is why most third-party payors, including Medicaid programs, base their requirements on Medicare standards.
That standard is conceptualized as “medical necessity.” A fundamental feature of medical necessity is, the “Golden Thread.” When the Golden Thread is employed, each element of the therapeutic process is clearly documented so that the connection between all aspects of clinical work flows logically from one record to the other. In-other-words, the criteria for a client needing services and the Golden Thread work together to justify medical necessity. At the same time, it is important that the clinician’s voice be heard in a narrative so that it is clear how they conceptualize the treatment rather than relying solely on a template with boiler plate drop down menus for all aspects of the record. This includes effectively documenting clinical progress while maintaining confidentiality. When clinical documentation is operationalized using this effective, efficient, and distinct procedure, medical records are clear, compliant and clinically useful. Documentation is necessary even for those psychotherapists who do not take insurance but still wish to meet professional, legal and ethical standards.
Applying the Documentation Wizard TM process to whatever system is used, increases accuracy and efficiency. It simultaneously reduces anxiety and resistance and contributes to quality care. The concepts and practice of this system are taught to Medicare standards and have a proven track record of success. Implementation of this system helps pass stringent Medicare audits, potentially saving clinics and clinicians thousands of dollars. Additionally, a reduction of time spent writing and rewriting paperwork, coupled with a significant increase in productivity and profits can lead to greater job satisfaction and less burnout. Choose mastery over misery and allow good clinical documentation to be a contribution to high quality care rather than a detour.
Beth Rontal, LICSW, is a nationally recognized and engaging speaker on clinical documentation for those working in agency behavioral health settings, as well as private practice clinicians. Her Documentation Wizard ™ training programs empower clinicians, reduce anxiety about documentation, and further professional integrity. She has created a formula that simplifies the documentation process by systematically linking effective documentation with quality care. This helps to pass audits and protect income. Beth mastered her teaching skills with thousands of hours supervising and training psychotherapists. She writes blogs on clinical documentation, co-chairs the NASW Private Practice Shared Interest Group, and has a private practice in Brookline, MA, specializing in working with people who struggle with emotional eating.
- Apply the clinical documentation process for writing successful session notes, treatment plans, case consults, discharge and intake summaries.
- Demonstrate how to translate your work into the behavioral language required by insurance companies.
- Apply the “golden thread” to justify medical necessity.
- Identify Red Flags that could trigger an audit.
9:30 – 10:00 AM
- Why is documentation the topic clinicians love to hate?
- Why document?
- Medical Necessity
- “The Golden Thread” and how it relates to medical necessity
How to Write a Treatment Plan
10:00 – 11:30 AM
- Definition of a treatment plan
- Everything that’s needed in a treatment plan and why
- How to write a treatment plan that justifies medical necessity using behavioral language and the “golden thread” with examples
11:30 – 11:45
Practice writing a treatment plan
11:45 – 12:15 PM
Lunch (on your own)
12:15 – 1:30 PM
How to Write a Session Note
1:30 – 2:45 PM
- Definition of a session note and how it relates to the treatment plan
- Everything that’s needed in a session note and why
- How to write a session note that justifies medical necessity using behavioral language and the “golden thread” with examples
- Practice writing a session note
2:45 – 3:00 PM
How to Write Case/Collateral Contact Note, Discharge Summary, Diagnostic Summary
3:00 – 4:15 PM
- Case/Collateral Contact Note
- Definition of a case/collateral contact note and how it relates to the treatment plan
- Everything that’s needed in a case/collateral contact note and why
- How to write a case/collateral Contact Note that justifies medical necessity using behavioral language and the “golden thread” with examples
- How to Write a Discharge Summary
- Definition of a discharge summary and how it relates to the treatment plan
- Everything that’s needed in a discharge summary and why
- How to write a discharge summary that completes the “golden thread” with examples
- How to Write an Intake or Diagnostic Summary
- Definition of an intake summary and how it relates to the other documentation
- Everything that’s needed in an intake summary and why
- How to write an intake summary that lays the ground for medical necessity
Red Flags and Wrap-up
4:15 – 5:00 PM
- What to identify that may triggering an audit
- Basic Do’s and Don’ts.
- Online or Paper Notes
There are a variety of reputable websites regarding best practice standards for documenting medical necessity. A few select sites include: Association for Behavioral Health Care; Massachusetts Standardized Documentation Project http://bit.ly/2NdzDET; Medical Documentation for Behavioral Health Practitioners 2015 at https://go.cms.gov/2EkA9OV; and a specific social work resource book Sidell, Nancy L. Social Work Documentation; a Guide to Strengthening Your Case Recording, NASW Press, Washington, DC, 2011. & revised edition, 2015 http://bit.ly/2Eh5yBt
social workers, psychologists, marriage and facility therapists, mental health counselors, creative arts therapists, addictions professionals, and other interested human service staff.
Beginning, Intermediate, Advanced
Continuing Education Credit is pending through Commonwealth Educational Seminars for psychologists, marriage and family therapists, mental health counselors.
Hawaii social workers are approved by NASW HI for 6 contact hours. AppID: F18T3-64.
Please note that it is the responsibility of the licensee to check with their individual state board to verify CE requirements for their state. Please click here to see all states that are covered for your licensure by Commonwealth Educational Seminars.
100% attendance is required. No partial credit will be awarded for partial attendance.
Psychologists, Marriage and Family Therapists, and Mental Health Counselors: once you complete the evaluation, you will receive Certificate Download Instructions, which will show you how to download your certificate.
Social Workers: once you complete the evaluation, you will be given a Certificate of Completion.
Commonwealth Educational Seminars (CES) seeks to ensure equitable treatment of every
person and to make every attempt to resolve grievances in a fair manner. Please submit a written grievance to Beth Rontal, firstname.lastname@example.org, and 617-522-6611. Grievances would receive, to the best of our ability, corrective action in order to prevent further problems.
The training site may not be handicap accessible. If you require any support for your ADA needs in Kaua'i, please contact Dennis Mendonca at: email@example.com or 808-652-2505 at least 3 weeks prior to the event. In Honolulu, please contact Beth Rontal at firstname.lastname@example.org at least 3 weeks prior to the event.