Our billers make sure that the patient’s ability to engage in and benefit from psychotherapy is included in the documentation for individual psychotherapy. There is a stated estimate of how many sessions the treatment will take. The patient’s health state or function is projected to improve as a result of the treatment, according to the medical record. The documented elements of therapy include target symptoms, goals, response to therapy, and techniques for tracking results.

Our billers make sure that the group psychotherapy documentation shows that cognitive skills—like reality-based discussion, supportive relationships, and behavior modification—were used to bring about therapeutic change. The participant’s participation and an assessment of its value—or lack thereof—are recorded in the record.

Anguish Points

In psychotherapy reviews, errors fall into three categories: not-covered services, not-documented services, and not-medically necessary treatments. Examples of errors we observe under each category are listed below.

1. Absence of paperwork or inadequate documentation

• For services rendered, no medical records were obtained.
• Not enough records to back up the degree of care that was billed.
• No record of the time spent in person with the patient.
• There is no record of the patient’s reaction to the psychotherapy interventions that were used
• The billing provider’s active involvement in the provided service is not properly recorded.

2. Services Not Covered

• People without licenses offering psychotherapy services 

3. Services Not Medically Necessary

• The absence of data regarding the patient’s ability to engage in and derive benefits from psychotherapy in their medical record does not suggest that their health status or function will improve as anticipated.