A message from Dr. William Beecroft, medical director of behavioral health
Consider these guidelines for documenting psychotherapy in 2021 and beyond

We’ve all had training on the important role that documentation plays in everything we do is. As changes occur within the health care industry, the documentation needs to evolve accordingly.

Over the past few years, there have been additional interventions behavioral health practitioners can provide to better address the needs of our patients — and these interventions need to be coded appropriately. Here are a few examples of some recent developments:

• During the COVID-19 pandemic, we witnessed a significant increase in the use of telemedicine services for patients. 
• The use of extended service codes has expanded in concert with the expansion of such treatments as:
• Evidence-based interventions, such as exposure response prevention therapy for obsessive compulsive disorder, anxiety and phobias.
• Eye movement desensitization, or EMDR, for trauma and post-traumatic stress disorder.
• Use of esketamine for the treatment of severe depression and suicidal thoughts. (This medication isn’t part of psychotherapy. It’s a new treatment that will require observation over time.)
• Crisis codes that have always been available are now easier to use — and documenting the interventions you perform becomes even more important. 
• Telephonic check-in visits and health assessments, including behavioral health assessments, have proliferated to provide more comprehensive care for patients.

As you know, the traditional 30- ,45- and 60-minute psychotherapy sessions have been a mainstay of the treatment process. Like any provider of a service to another individual, documenting the items that were addressed during the time you’re billing for is essential. It’s not only important for reimbursement purposes, but to retain as background in case a patient asks what you’ve done for them. In addition, regulatory agencies may ask to see your records to assess your treatment practices or courts may request documentation related to the consequences of an injury.

The main tenet to keep in mind is this: If it’s not written, you didn’t do it.

Clinically, there’s evidence that “treating to target” is the gold standard of care. For example, treating diabetes to a A1c less than 7 or treating depression to a PHQ-9 less than 5 is necessary to show the progress and eventual success of your intervention. Using this model proves your dedication to quality and adherence to scientific methods, along with the art of behavioral health interventions.

Blue Cross Blue Shield of Michigan and Blue Care Network want you to get reimbursed for the work you do but, at the same time, we want you to bill us appropriately for that work. Documenting what has transpired in the practice setting will support that.

Much like the architect designing a building will document the time and tasks represented in their bill, we expect you to document the components of the work you’re doing and objectively justify that the interventions are for the member’s best interest.

For many years, we’ve required the elements below in your documentation to support medical necessity:

• Date of the visit and the start and stop times
• Names of those present during the session. (If separate individuals are interviewed, include the duration each is present. Identify the service provided.)
• Updated medical history and current medications (changes) along with the name of the prescribing medical provider and evidence that coordination of care has occurred at least quarterly
• Clinical findings on reexamination
• Brief indication of the patient’s reaction to therapeutic intervention (for example, “The patient is open to treatment suggestions” or “The patient is reluctant to make recommended changes.”)
• Objectively stated treatment plan and rationale, if changed from the last visit
• Results of objective screening or monitoring tools to gauge improvement
• Instructions, recommendations and precautions given to the patient or other significant parties
• Signature and credentials of the treating provider and by the supervisor, as applicable

In my opinion, this would be a minimum needed for good documentation that truly reflects your work. See the full documentation requirements for more details.

The American Psychological Association also has guidelines* you may want to check out.

At Blue Cross, we appreciate all you do to take care of our members. We recognize this is a big responsibility and we value your partnership. We hope the information in this column will help you stay current on documentation and practice trends that are changing rapidly as the clinical science evolves.

William Beecroft, M.D. is medical director of behavioral health for Blue Cross Blue Shield of Michigan and Blue Care Network.

*Blue Cross Blue Shield of Michigan doesn’t own or control this website.

Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association.