This seminar will provide a comprehensive exploration of documentation requirements and payer policies for psychiatric diagnostic evaluations, associated treatment plans, and evaluation and management services in the outpatient setting specific to prescribing psychologists. We will carefully explore how to determine the complexity of medical decision-making based on the American Medical Association’s guidelines. We will also consider time-based coding of evaluation and management services, to include activities that may and may not be counted towards total time, documentation necessities and strategies for accurate reporting and reimbursement. Additionally, we will explore therapeutic services such as individual psychotherapy and psychotherapy for crisis.
As variable payer policies exist, we will also explore similarities and differences for several top payers. This will include how to report prolonged services for Medicare and other payers, requirements regarding start and stop time versus total service time, and treatment plan specifics. Both internal and external audits are a key component of a robust compliance plan. Understanding variable requirements will allow organizations to set internal documentation standard policies that ensure payer requirements are met or exceeded in all circumstances.
Throughout the seminar, redacted records will be used to practice application of seminar content. Both excellent and poor documentation examples will be shared. Attendees will break into groups to assess record quality, determine which documentation components are absent to support the service, and select appropriate levels of service, where applicable. This activity will assist attendees in applying documentation standards to their own encounter records and appropriately assigning supported service codes.