Paperwork for Medicare Cases
with Older Adults
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GerontologyA Training Resource By Jim Messina, Ph.D., CCMHC, NCC, DCMHS-T NOTE: Important Medicare Links at end of this page
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Client Medicare Forms to Be Used
The following are sample forms with fictional patients which are used when counseling aging seniors under Medicare regulations.
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Form 1: Client Consent Form
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY
USES AND DISCLOSURE OF HEALTH INFORMATION
We are committed to protecting the privacy of the personal and health information we collect or create as part of providing health care services to our clients, known as “Protected Health Information” or “PHI”. PHI typically includes your name, address, date of birth, billing arrangements, care and other information that relates to your health, health care provided to you or payment for health care provided to you. PHI does not include information that is de-identified or cannot be linked to you.
This notice of Health Information Privacy Practices (the “Notice”) describes our duties with respect to the privacy of PHI, our use of and disclosure of PHI, client rights and contact information for comments, questions and complaints.
OUR PRIVACY PROCEDURES AND LEGAL OBLIGATIONS
We obtain most of your PHI directly from you, through care applications, assessments and direct questions. We may collect additional personal information depending upon the nature of your needs and consent to make additional referrals and inquiries. We may also obtain PHI from community health care agencies, other governmental agencies or health care providers as we set up your service arrangements.
We are required by law to provide you with this notice and to abide by the terms of the Notice currently in effect. We reserve the right to amend this Notice at any time to reflect changes in our privacy practices. Any such changes will be applicable to and effective for all PHI that we maintain including PHI we created or received prior to the effective date of the revised notice. Any revised notice will be mailed to you or provided upon request.
We are equired by law to maintain the privacy of PHI. We will comply with federal law and will comply with any state law that further limits or restricts the uses and disclosures discussed below. In order to comply with these state and federal laws, We have adopted policies and procedures that require its employees to obtain, maintain, use and disclose PHI in a manner that protects client privacy.
USES AND DISCLOSURES WITH YOUR AUTHORIZATION
Except as outlined below, we will not use or disclose your PHI without your written authorization. The authorization form is available from us (at the address and phone number below). You have the right to revoke your authorization at any time, except to the extent that we have taken action in reliance on the authorization.
The law permits us to use and disclose your PHI for the following reasons without your authorization:
For Your Treatment: We may use or disclose your PHI to physicians, psychologists, nurses and other authorized healthcare professionals who need your PHI in order to conduct an examination, prescribe medication or otherwise provide health care services to you.
To Obtain Payment: We may use or disclose your PHI to insurance companies, government agencies or health plans to assist us in getting paid for our services. For example we may release information such as dates of treatment to an insurance company in order to obtain payment.
For Our Health Care Operations: We may use or disclose your PHI in the course of activities necessary to support our health care operations such as performing quality checks on your employee services. We may also disclose PHI to other persons not in our workforce or to companies who help us perform our health services (referred to as ‘Business Associate’s “) we require these business associates to appropriately protect the privacy of your information .
As Permitted or Required By The Law: In some cases we are required by law to disclose PHI. Such as disclosers may be required by statute, regulation court order, government agency, we reasonably believe an individual to be a victim of abuse, neglect or domestic violence: for judicial and administrative proceedings and enforcement purposes.
For Public Health Activities: We may disclose your PHI for public health purposes such as reporting communicable disease results to public health departments as required by law or when required for law enforcement purposes.
For Health Oversight Activities: We may disclose your PHI in connection with governmental oversight, such as for licensure, auditing and for administration of government benefits. The State Department of Human Services is an example of an agency that oversees our operations.
To Avert Serious Threat to Health and Safety: We may disclose PHI if we believe in good faith that doing so will prevent or lessen a serious or imminent threat to the health and safety of a person or the public.
Disclosures of Health Related Benefits or Services: Sometimes we may want to contact you regarding service reminders, health related products or services that may be of interest to you, such as health care providers or settings of care or to tell you about other health related products or services offered by us. You have the right not to accept such information.
Incidental Uses and Disclosures: Incidental uses and disclosures of PHI are those that cannot be reasonably prevented, are limited in nature and that occur as a by-product of a permitted use or disclosure. Such incidental used and disclosures are permitted as long as we use reasonable safeguards and use or disclose only the minimum amount of PHI necessary.
To Personal Representatives: We may disclose PHI to a person designated by you to act on your behalf and make decisions about your care in accordance with state law. We will act according to your written instructions in your chart and our ability to verify the identity of anyone claiming to be your personal representative.
To Family and Friends: We may disclose PHI to persons that you indicate are involved in your care or the payment of care. These disclosures may occur when you are not present, as long as you agree and do not express an objection. These disclosures may also occur if you are unavailable, incapacitated or facing an emergency medical situation and we determine that a limited disclosure may be in your best interest. We may also disclose limited PHI to public or private entity that is authorized to assist in disaster relief efforts in order for that entity to locate a family member or other person that may be involved in caring for you. You have the right to limit or stop these disclosures.
EXCEPTIONS TO CONFIDENTIALITY
Records may not be disclosed without the written consent of the individual to whom they pertain except that appropriate disclosure may be made without such consent in the following exceptions, which are listed below:
∙ To medical personnel in a medical emergency.
∙ To service provider personnel if such personnel need to know the information in order to carry out duties relating to the provision of services to an individual.
∙ To the secretary of the department or the secretary’s designee, for purposes of scientific research, in accordance with federal confidentiality regulations, but only upon agreement in writing that the individual’s name and other identifying information will not be disclosed.
∙ In the course of review of service provider records by persons who are performing an audit or evaluation on behalf of any federal, state, or local government agency, or third-party payor providing financial assistance or reimbursement to the service provider; however, reports produced as a result of such audit or evaluation may not disclose names or other identifying information and must be in accordance with federal confidentiality regulations.
∙ Upon court order based on application showing good cause for disclosure.
∙ To police, if a crime is committed on facility property or upon a staff member, visitor, or other client.
Notifications to medical personnel in a medical emergency:
∙ Disclosures to medical personnel can be made if there is a determination that a medical emergency exists, i.e., there is a situation that poses an immediate threat to the health of any individual and requires immediate medical intervention [42 CFR §2.51(a)]. Information disclosed to the medical personnel who are treating such a medical emergency may be re-disclosed by such personnel for treatment purposes as needed.
∙ Clients’ identifying information may be disclosed to medical personnel who have a need for information about a Client for the purpose of treating a condition which poses an immediate threat to the health of any individual and which requires immediate medical intervention.
∙ Client identifying information may be disclosed to medical personnel of the Food and Drug Administration (FDA) who assert a reason to believe that the health of any individual may be threatened by an error in the manufacture, labeling, or sale of a product under FDA jurisdiction, and that the information will be used for the exclusive purpose of notifying Clients or their physicians of potential dangers.
∙ Immediately following disclosure, the staff member who made the disclosure shall document the disclosure in the client's records including the following.
Notifications to law enforcement:
∙ Law enforcement agencies can be notified if an immediate threat to the health or safety of an individual exists due to a crime on the facility premises or against staff. Staff are permitted to report the crime or attempted crime to a law enforcement agency or to seek its assistance [42 CFR] §2.12(c)(5)]. Part 2 permits disclosure of information regarding the circumstances of such incident, including the suspect’s name, address, last known whereabouts, and status as a client at the facility.
∙ The restrictions on disclosure and use in this section do not apply to communications from provider personnel to law enforcement officers which:
∙ Are directly related to an individual’s commission of a crime on the premises of the provider or against provider personnel or to a threat to commit such a crime; and
∙ Are limited to the circumstances of the incident, including the status of the individual committing or threatening to commit the crime, that individual’s name and address, and that individual’s last known whereabouts.
∙ The restrictions on disclosure and use in this section do not apply to the reporting of incidents of suspected child abuse and neglect to the appropriate state or local authorities as required by law. However, such restrictions continue to apply to the original substance abuse records maintained by the provider, including their disclosure and use for civil or criminal proceedings which may arise out of the report of suspected child abuse and neglect.
Court ordered disclosures:
∙ Under the regulations, Part 2 programs or “any person having a legally recognized interest in the disclosure which is sought” may apply to a court for an order authorizing disclosure of protected patient information [42 CFR § 2.64]. Thus, if there is an existing threat to life or serious bodily injury, a Part 2 program or “any person having a legally recognized interest in the disclosure which is sought” can apply for a court order to disclose information.
∙ An order of a court of competent jurisdiction authorizing disclosure and use of confidential information is a unique kind of court order. Its only purpose is to authorize a disclosure or use of identifying information which would otherwise be prohibited by this section. Such an order does not compel disclosure. A subpoena or a similar legal mandate must be issued in order to compel disclosure. This mandate may be entered at the same time as, and accompany, an authorizing court order entered under this section.
∙ An order authorizing the disclosure of an individual’s records may be applied for by any person having a legally recognized interest in the disclosure which is sought. The application may be filed separately or as part of a pending civil action in which it appears that the individual’s records are needed to provide evidence. An application must use a fictitious name, such as John Doe or Jane Doe, to refer to any individual and may not contain or otherwise disclose any identifying information unless the individual is the applicant or has given a written consent to disclosure or the court has ordered the record of the proceeding sealed from public scrutiny.
∙ Any answer to a request for a disclosure of individual records which is not permissible under this section or under the appropriate federal regulations must be made in a way that will not affirmatively reveal that an identified individual has been, or is being diagnosed or treated for substance abuse. The regulations do not restrict a disclosure that an identified individual is not and has never received services.
∙ The individual and the person holding the records from whom disclosure is sought must be given adequate notice in a manner which will not disclose identifying information to other persons, and an opportunity to file a written response to the application, or to appear in person, for the limited purpose of providing evidence on the statutory and regulatory criteria for the issuance of the court order.
∙ Any oral argument, review of evidence, or hearing on the application must be held in the judge’s chambers or in some manner which ensures that identifying information is not disclosed to anyone other than a party to the proceeding, the individual, or the person holding the record, unless the individual requests an open hearing. The proceeding may include an examination by the judge of the records referred to in the application.
∙ A court may authorize the disclosure and use of records for the purpose of conducting a criminal investigation or prosecution of an individual only if the court finds that all of the following criteria are met:
∙ The crime involved is extremely serious, such as one which causes or directly threatens loss of life or serious bodily injury, including but not limited to homicide, sexual assault, sexual battery, kidnapping, armed robbery, assault with a deadly weapon, and child abuse and neglect.
∙ There is reasonable likelihood that the records will disclose information of substantial value in the investigation or prosecution.
∙ Other ways of obtaining the information are not available or would not be effective.
∙ The potential injury to the individual, to the physician-individual relationship, and to the ability of the facility to provide services to other individuals is outweighed by the public interest and the need for the disclosure.
Research: Client identifying information may be disclosed for the purpose of conducting scientific research if the Clinical Director makes a determination that the recipient of the Client identifying information:
∙ Is qualified to conduct the research;
∙ Has a research protocol under which the client identifying information:
∙ Will be maintained in accordance with the security requirements of § 2.16 of these regulations (or more stringent requirements); and
∙ Will not be re-disclosed except as permitted under paragraph (b) of this section;
∙ Has provided a satisfactory written statement that a group of three or more individuals who are independent of the research project has reviewed the protocol and determined that:
∙ The rights and welfare of clients will be adequately protected;
∙ The risks in disclosing patient identifying information are outweighed by the potential benefits of the research.
∙ A person conducting research may disclose client identifying information only back to the program from which that information was obtained and may not identify any individual client in any report of that research or otherwise disclose client identities.
Audit and Evaluation: If client records are not copied or removed, client identifying information may be disclosed in the course of a review of records on facility premises to any person who agrees in writing to comply with the limitations on re-disclosure and use and who:
∙ Performs the audit or evaluation activity on behalf of:
∙ Any Federal, State, or local governmental agency which provides financial assistance to the program or is authorized by law to regulate its activities; or
∙ Any private person which provides financial assistance to the facility, which is a third party payer covering clients in the program, or which is a quality improvement organization performing a utilization or quality control review; or
∙ Is determined by the Clinical Director to be qualified to conduct the audit or evaluation activities.
∙ Records containing client identifying information may be copied or removed from program premises by any person who:
∙ Agrees in writing to:
∙ Maintain the client identifying information in accordance with the security requirements provided in § 2.16 of these regulations (or more stringent requirements);
∙ Destroy all the client identifying information upon completion of the audit or evaluation;
∙ Comply with the limitations on disclosure and use
∙ Performs the audit or evaluation activity on behalf of:
∙ Any Federal, State, or local governmental agency which provides financial assistance to the facility or is authorized by law to regulate its activities; or
∙ Any private person which provides financial assistance to the facility, which is a third part payer covering clients in the program, or which is a quality improvement organization performing a utilization or quality control review.
∙ Client identifying information disclosed may be disclosed only back to the facility from which it was obtained and used only to carry out an audit or evaluation purpose or to investigate or prosecute criminal or other activities, as authorized by a court order entered under § 2.66 of these regulations.
Immediate threats to health and/or safety: Immediate threats to health or safety that do not involve medical emergencies or crimes on facility premises or against staff: Part 2 programs and health care providers and HIOs who have received Part 2 client information, can make reports to law enforcement about an immediate threat to the health or safety of an individual or the public if client-identifying information is not disclosed. Immediate threats to health or safety that do not involve a medical emergency or crimes (e.g., a fire) are not addressed in the regulations. The facility will evaluate those circumstances individually.
Reports of child or vulnerable adult abuse and neglect: The restrictions on disclosure do not apply to the reporting under State law of incidents of suspected child abuse and neglect to the appropriate State or local authorities. However, Part 2 restrictions continue to apply to the original alcohol or drug abuse client records maintained by the facility including their disclosure and use for civil or criminal proceedings which may arise out of the report of suspected child abuse and neglect [42 CFR § 2.12(c)(6)]. Also, a court order under Part 2 may authorize disclosure of confidential communications made by a client to a facility in the course of diagnosis, treatment, or referral for treatment if, among other reasons, the disclosure is necessary to protect against an existing threat of life or of serious bodily injury, including circumstances which constitute suspected child abuse and neglect [42 CFR § 2.63(a)(1)].
YOUR RIGHTS CONCERNING PRIVACY
Access to Certain Records: You have the right to inspect and copy your PHI in a designated record set except where State law may prohibit client access. A designated record set contains medical and billing and case management information. If we do not have your PHI record set but know who does, we will inform you how to get it. If our PHI is a copy of information maintained by another health care provider, we may direct you to request the PHI from them. If we produce copies for you, we may charge you up to $1.00 per page up to a maximum fee of $50.00. Should we deny your request for access to information contained in your designated record set, you have the right to ask for the denial to be reviewed by another healthcare professional designated byus.
Amendments to Certain Records: You have the right to request certain amendments to your PHI if for example, you believe a mistake has been made or vital piece of information is missing. We are not required to make the requested amendments and will inform you in writing of our response to your request.
Accounting of Disclosures: You have the right to receive an accounting of disclosures of your PHI that were made by us for a period of six (6) years prior to the date of your written request. This accounting does not include for purposes of treatment, payment, health care operations or certain other excluded purposes, but includes other types of disclosures, including disclosures for public health purposes or in response to a subpoena or court order.
Restrictions: You have the right to request that we agree to restrictions on certain uses and disclosures of your PHI but we are not required to agree to your request. You cannot place limits on uses and disclosures that we are legally required or allowed to make.
Revoke Authorizations: You have the right to revoke any authorizations you have provided, except to the extent that we have already relied upon the prior authorization.
Delivery by Alternate Means or Alternate Address: You have the right to request that we send your PHI by alternate means or to an alternate address.
Complaints & How to contact us: If you believe your privacy rights have been violated, you have the right to file a complaint by contactingus at the address and/or phone number indicated below. You also have the right to file a complaint with the Secretary of the United States Department of Health and Human services in Washington, D.C. We will not retaliate against you for filing a complaint.
If you believe your privacy rights have been violated, you may make a complaint by contacting compliance officer at ____________or the Secretary for the Department of Health and Human Services. No individual will be retaliated against for filing a complaint.
The U.S. Department of Health and Human Services, 200 Independence Avenue, S.W.,Washington, D.C. 20201; Toll Free: 1-877-696-6775
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Documentation Tips for Medicare Reports
1. If you may find that it would be helpful to receive blank, paper versions of each of the forms so you can capture needed data without using your electronic device, so ask your contractor for blank forms.
2. You are strongly advised to consider concurrent note writing within your sessions (and just after your sessions) so there is no documentation work to take home at the end of the day and no memory decay. Simply see your patients, document, get a copy on the medical chart in the facility, and your work is finished for that visit! You MUST have the clinical documentation on the client chart no later than 7 days from your date of service.
3. Read the guiding prompts in the EHR to confirm what you are intended to document in each field. Do not freelance/go off track! Do not skip any sections. If a field does not apply, write N/A or WNL (within normal limits) so it does not appear you overlooked or skipped that field.
4. When documenting, ask yourself, “What does this statement have to do with the primary Dx I am billing under this date of service?” If the answer is “nothing,” then delete or modify it!
5. There always should be a connection back to the treating diagnosis and treatment goals for the patient. Remember, we are not necessarily working toward a cure, but toward stabilization and maximization of physical, cognitive, & mental functioning. You are being paid by insurance companies to move their beneficiaries through the stages of change they can achieve at this time. Once gains are maximized, discharge the patient from that specific episode of care.
6. Note MEASURABLE progress (even if very minor) toward goals. Medicare wants to be able to directly see in your notes your chosen method of monitoring outcomes and progress toward change. You cannot just say, “Patient is progressing.” Your formula should be, “Patient is progressing AS EVIDENCED BY...” Use #s, %s, scores, reports - things that can be counted and actually measured over time.
7. Focus on affect, behaviors, and cognitions of the patient that can be seen and measured. Consistently report quantifiable outcomes! Utilize the various assessment scales provided to you during orientation to measure patient functioning at “baseline” and again over time as
“measures of progress.”
8. Do not succumb to the trap of the "complaint of the day." Tie session conversation to the Dx you are treating/billing under and the master treatment plan, as you maintain focus on what the patient can do differently to impact their quality of life and optimal physical and mental health functioning. You are being paid to move patient from point A to point B with their thoughts, feelings, and behaviors.
9. Document the value of your service and concrete progress (or the reason therapy must continue to prevent back-sliding or decompensation). Your treatment plan must have specific and Measurable Goals
10. Only document information that is "need to know" (HIPAA’s minimum necessary standard). That is, providers should document DIPLOMATICALLY the minimal amount of detail needed to communicate key themes but not unnecessarily reveal sensitive information that could jeopardize the patient or facility or that is a violation of patient privacy. A large audience will read your notes in the patient chart. In this integrated medical setting, you are part of the larger healthcare team. Do not make the facility or other care providers look bad.
1. If you find that it would be helpful to receive blank, paper versions of each of the forms so you can capture needed data without using your electronic device, please email Natalie Cotler to request the blank forms be emailed to you.
2. You are strongly advised to consider concurrent note writing within your sessions (and just after your sessions) so there is no documentation work to take home at the end of the day and no memory decay. Simply see your patients, document, get a copy on the medical chart in the facility, and your work is finished for that visit! You MUST have the clinical documentation on the client chart no later than 7 days from your date of service.
3. Read the guiding prompts in the EHR to confirm what you are intended to document in each field. Do not freelance/go off track! Do not skip any sections. If a field does not apply, write N/A or WNL (within normal limits) so it does not appear you overlooked or skipped that field.
4. When documenting, ask yourself, “What does this statement have to do with the primary Dx I am billing under this date of service?” If the answer is “nothing,” then delete or modify it!
5. There always should be a connection back to the treating diagnosis and treatment goals for the patient. Remember, we are not necessarily working toward a cure, but toward stabilization and maximization of physical, cognitive, & mental functioning. You are being paid by insurance companies to move their beneficiaries through the stages of change they can achieve at this time. Once gains are maximized, discharge the patient from that specific episode of care.
6. Note MEASURABLE progress (even if very minor) toward goals. Medicare wants to be able to directly see in your notes your chosen method of monitoring outcomes and progress toward change. You cannot just say, “Patient is progressing.” Your formula should be, “Patient is progressing AS EVIDENCED BY...” Use #s, %s, scores, reports - things that can be counted and actually measured over time.
7. Focus on affect, behaviors, and cognitions of the patient that can be seen and measured. Consistently report quantifiable outcomes! Utilize the various assessment scales provided to you during orientation to measure patient functioning at “baseline” and again over time as
“measures of progress.”
8. Do not succumb to the trap of the "complaint of the day." Tie session conversation to the Dx you are treating/billing under and the master treatment plan, as you maintain focus on what the patient can do differently to impact their quality of life and optimal physical and mental health functioning. You are being paid to move patient from point A to point B with their thoughts, feelings, and behaviors.
9. Document the value of your service and concrete progress (or the reason therapy must continue to prevent back-sliding or decompensation). YOUR TREATMENT PLAN MUST HAVE SPECIFIC &
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CPT Codes
The Current Procedural Terminology (CPT) codes are used to identify procedures therapist perform when providing psychotherapy services. The Health Insurance Portability and Accountability Act (HIPAA) has designated CPT as the national coding standard for reporting procedures for health care professionals. CPT provides a uniform language to describe psychotherapy and other health services.
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CPT Codes
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CPT Code
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Interactive complexity add-on (for psychotherapy codes)
Code 90785 is an add-on code for interactive complexity to be reported in conjunction with codes for diagnostic psychiatric evaluation (90791, 90792), psychotherapy (90832, 90834, 90837), psychotherapy when performed with an evaluation and management service (90833, 90836, 90838, 99202–99255, 99304–99337, 99341–99350) and group psychotherapy (90853)
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90785
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Psychiatric diagnostic evaluation
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90791
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Psychiatric diagnostic evaluation with medical services
(Use 90785 in conjunction with 90791, 90792 when the diagnostic evaluation includes interactive complexity services)
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90792
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Psychotherapy, 30 minutes with patient
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90832
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Psychotherapy, 30 minutes with patient when performed with an evaluation and management service (List separately in addition to the code for primary procedure)
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90833
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Psychotherapy, 45 minutes with patient
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90834
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Psychotherapy, 45 minutes with patient when performed with an evaluation and management service (List separately in addition to the code for primary procedure)
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90836
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Psychotherapy, 60 minutes with patient
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90837
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Psychotherapy, 60 minutes with patient when performed with an evaluation and management service (List separately in addition to the code for primary procedure)
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90838
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Psychotherapy for crisis; first 60 minutes
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90839*
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Psychotherapy for crisis add-on—Each additional 30 minutes (List separately in addition to code for primary service)
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90840
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Family psychotherapy (without the patient present), 50 minutes
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90846
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Family psychotherapy, conjoint therapy (with the patient present), 50 minutes
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90847
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Multiple-family group psychotherapy
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90849*
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Group psychotherapy (other than of a multiple-family group)
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90853*
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Description of CPT Codes
90791
The psychiatric diagnostic evaluation is an integrated biopsychosocial assessment which includes a history, mental status, and recommendation. It may include communication with family and other sources who are considered informants. 90791 does not include psychotherapeutic services and can only be reported once per day per patient. This code may be used for a reassessment or it can be used more than once for an initial assessment if more time is required. There is no time range for this code.
90832, 90834, and 90837
90832, 90834, and 90837 describe individual psychotherapy services for the patient and may include an informant. The codes include an ongoing assessment and adjustment of treatment interventions. The times for these codes are:
• 90832 – Psychotherapy 30 minutes. Time range: 16 to 37 minutes
• 90834 – Psychotherapy 45 minutes. Time range: 38 to 52 minutes
• 90837 – Psychotherapy 60 minutes. Time range: 53 minutes or more
Some health insurance companies may consider 90834 as the standard psychotherapy session. In such cases when reporting 90837, it would be beneficial to document in the clinical record why the longer service was warranted rather than the shorter service.
90785
90785 is an add-on code used to report interactive complexity services. It is reported in conjunction with 90791, 90832, 90834, and 90837. Interactive complexity is a special communication factor that complicates the delivery of psychotherapy services. It is commonly used when delivering services to children and verbally undeveloped or impaired patients. These patients usually have third parties such as parents, guardians, interpreters, schools, and court officers.
90839 and 90840
90839 and 90840 are codes used to report psychotherapy for crises. These codes report an urgent assessment which includes a history of a crisis state, a mental status exam, and a disposition. Treatment includes: • Psychotherapy • Mobilization of resources to defuse the crisis and restore safety • Provision of psychotherapeutic intervention to minimize emotional trauma. For 90839 and 90840, the presenting problem is life threating or complex, and requires immediate attention to a patient in high distress. Therapists must devote their full attention to the patient, and cannot provide services to another patient during the same time period. The times for these codes are:
- 90839 – Psychotherapy for crisis, the first 60 minutes. The time range is 30-74 minutes
- 90840 – Psychotherapy for crisis, each additional 30 minutes. Report additional blocks of time up to 30 minutes each beyond 74 minutes
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90846
90846 identifies family psychotherapy services without the patient present. This code may be used on the same day as an individual psychotherapy service is provided when the services are separate and distinct for the patient. The session is for 50 minutes and the time range is 26 minutes or more
90847
90847 is family psychotherapy with the patient present. This is also referred to as conjoint psychotherapy. This code may also be used on the same day as an individual psychotherapy service is provided as long as the services are separate and distinct for the patient. The time is a 50 minute session and the time range is 26 minutes or more.
90853
90853 is for group psychotherapy. When appropriate, the add-on code for interactive complexity, 90785, may be used with this code. There is no time specification for this code
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Reporting Clinical Interventions
Below, please find examples of possible verbiage you may find useful in documenting the description of what therapy entailed and how it addressed the presenting problem or diagnosis section of the Progress Note. You must capture what you did (that only licensed therapists can do!) to help the patient’s primary diagnosis you are billing under this date of service. Do not document activities that volunteers, chaplains, family members, pet owners, etc. can do naturally as your chosen “psychotherapy.”
For example, you cannot just say, “Used CBT today.” Rather, say, “Used CBT and psychoeducation to teach interplay betwen thoughts and behaviors. Patient admitted that his outbursts toward staff reflect his internal feeling and thinking. Linked treatment non-compliance to despair and underlying grief/loss of limb. Discussed importance of homework assignment to assist in meeting outcomes/goals.”
Anger Management: Provided psychoeducation on how repressed anger and anger turned inward can contribute to client’s feelings of depression. Explored strategies to appropriately deal with feelings of anger, reframe meaning of situations, and gently challenged tendencies toward automatic negative self-talk. Taught & rehearsed “count to 10” skill.
Behavior Management: Using Pleasant Events Schedule, identified desirable reinforcers to increase motivation for complying with hygiene care. Worked with key nurses to establish an intermittent schedule of reinforcement and educated on shaping principle so client can be both prompted/cued and rewarded for increasing rate of target behavior. Will follow-up next visit to ensure staff are consistently sticking to behavior plan to shape patient behavior.
CBT: CBT interventions used to focus on reducing the stress-producing cognitive patterns that give rise to muscle tension that increases pt’s pain response and irritability underlying clinical depression Dx. OR… Explored patient’s beliefs about pain and its controllability. Reviewed cognitive errors, particularly patient’s catastrophizing and overgeneralizations about pain and degree of perceived disability. Reviewed behavioral coping strategies within her control, including use of relaxation and problem-solving strategies.
Existential Psychotherapy: Explored recent increase in symptoms of anxiety and onset of fears about mortality. Assisted client in reflecting on beliefs about current purpose/meaning in life. Taught concept of “Story Line” and discussed possible paths his life can take now and in future to create desired meaning, promote sense of agency, and build authentic choices. Client stated he suspects this will have an impact on symptoms. Will administer Beck Anxiety Scale next visit to compare to baseline from two weeks ago.
Motivational Interviewing: Used Motivational Interviewing strategy of Socratic questioning, helped client explore and compare their personal goals to their present state, helping to highlight discrepancies and motivate change. Identified client’s true PT and OT goals and provided reality testing to ensure goals are attainable. Will follow up with rehab team to update on progress made this visit and request positive reinforcement of small strides patient is able to commit to making over next four weeks to buffer against further ambivalence about pain vs regaining full functioning.
Biopsychosocial Education: Utilized in family session to help family understand the importance of social support for the client and how can impact both their physical health as well as emotional health. Explored ways to help increase support for client from within the family as well as through community sources (e.g., church group, JCC, Senior Center).
Grief/Bereavement Therapy: History of Loss Graph initiated in session to help the client explore and identify the losses in their life, identify what issues may still need to be resolved, and identify past coping strategies successfully used.
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CONSENT FOR THERAPY/EVALUATION
THE PROCESS OF THERAPY/EVALUATION Psychotherapy is not easily described in general statements. It varies depending on the personalities of the therapist and client and the particular problems you bring forward. There are many different methods that therapists may use to deal with the problems you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for therapy to be most successful, you will have to work on things talked about in our sessions.
Psychotherapy can have benefits and risks. Since therapy sometimes involves discussing unpleasant aspects of your life, you may at times experience uncomfortable feelings such as sadness, guilt, anger, frustration, loneliness, and helplessness. At the same time, psychotherapy has been shown to have many positive benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. There are no guarantees of what you will experience, however.
Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships, may result in changes that were not originally intended. Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing or relationships. Sometimes a decision that is positive for one family member is viewed quite negatively by another family member. Sometimes change will be easy and swift, but it can also be slow and even frustrating.
The first one or two meetings will involve a discussion of your concerns and other important aspects of your life. These meetings allow the therapist to get to know you and to have a context in which to understand your goals. By the end of the evaluation, your therapist will be able to assess if he/she can be of benefit to you. If so, your therapist will give you an initial plan of what your work together will include. During the course of working together, your therapist may ask you for your feedback and views on your therapy, its progress or about other aspects of the therapy. You are encouraged to respond openly and honestly. It is always appropriate for you to ask questions about your therapy and your therapist’s view of your progress. Therapists do their best to create an atmosphere in which you feel safe to disclose your true thoughts and feelings.
We look forward to working with you to help you successfully face the challenges in your life. Your signature below indicates that you have read this Consent and understand it.
Client's Signature Client's Name (please print)
Parent/Guardian's Signature if client is a minor Date
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Notice of Privacy Policies & Practices
Your Information. Your Rights. Our Responsibilities. This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
I. Uses and Disclosures for Treatment, Payment, and Healthcare Operations
We may use and disclose your Protected Health Information (PHI) for treatment, payment, and healthcare operations with your consent. To help clarify these terms, here are some definitions.
“PHI” refers to information in your health record that could identify you.
"Use” applies only to activities within Associates in Health Psychology such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you
“Disclosure” applies to activities outside of our practice, such as releasing, transferring, or providing access to information about you to other parties.
Psychotherapy Notes: Notes recorded by your therapist documenting the contents of a counseling session with you ("Psychotherapy Notes") will be used only by your therapist and will not otherwise be used or disclosed without your written authorization. Psychotherapy Notes are given a greater degree of protection than PHI.
Other Uses and Disclosures: Uses and disclosures other than those described in Section I. above will only be made with your authorization. For example, you will need to sign an authorization form before AHP can send PHI to your life insurance company, to a school, or to your attorney. You may revoke any such authorization at any time.
Child Abuse: If a therapist knows or in good faith suspects child abuse or neglect, the therapist is required to report such knowledge or suspicion to the appropriate authority.
Adult and Domestic Abuse: If a therapist has reasonable cause to believe that an adult person is infirm or incapacitated and in need of protective services, the therapist must report such information to the State Department of Health and Social Services.
Health Oversight Activities: If the Division of Professional Regulation is investigating our practice, we must comply with any subpoenas issued by the Division.
Judicial and Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law, we will not release information without the written authorization of you or your legally appointed representative or
Serious Threat to Health or Safety: If you communicate to your therapist an explicit and imminent threat to kill or seriously injure a clearly identified victim or victims, or to commit a specific violent act or to destroy property under circumstances which could easily lead to serious personal injury or death, and you have an apparent intent and ability to carry out the threat, the therapist may disclose information in order to provide protection for the identified victim. If your therapist believes that there is an imminent risk that you will inflict serious physical harm on yourself, the therapist may disclose information in order to protect you.
Privacy Rule Exceptions: When the use and disclosure without your consent or authorization is allowed under other sections of Section 164.512 of the Privacy Rule and the state’s confidentiality law. This includes certain narrowly- defined disclosures to law enforcement agencies, to a health oversight agency (such as HHS or a state department of health), to a coroner or medical examiner, for public health purposes relating to disease or FDA-regulated products, or for specialized government functions such as fitness for military duties, eligibility for VA benefits, and national security and intelligence.
Right to Restrict Disclosures When You Have Paid for Your Care Out-of-Pocket. You have the right to restrict certain disclosures of PHI to a health plan when you pay out-of-pocket in full for our services.
Right to Request Other Restrictions: You have the right to request other restrictions on certain uses and disclosures of protected health information. However, we are not required to agree to your request.
Right to Inspect and Copy: You have the right to inspect or obtain a copy (or both) of PHI in the your mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. We may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed.
Right to Request Amendment: You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. Your request must be in writing, and it must explain why the information should be amended. We may deny your request under certain circumstances.
Right to an Accounting: You generally have the right to receive an accounting of disclosures of PHI for purposes other than treatment, payment or health care operations, excluding disclosures made to you or disclosures otherwise authorized by you. On your request, we will discuss with you the details of the accounting process.
Right to Be Notified if There is a Breach of Your Unsecured PHI. You have a right to be notified if: (a) there is a breach (a use or disclosure of your PHI in violation of the HIPAA Privacy Rule) involving your PHI; (b) that PHI has not been encrypted to government standards; and (c) my risk assessment fails to determine that there is a low probability that your PHI has been compromised.
Right to a Paper Copy: You have the right to obtain a paper copy of our Privacy Notice upon request to your therapist or the office staff at any time.
Questions and Complaints: You may contactus with questions or complaints. You may also file written complaints with the Director, Office for Civil Rights of the U.S. Department of Health and Human Services. We will not retaliate against you if you file a complaint.
B. “Treatment, Payment and Health Care Operations”
Treatment is providing, coordinating or managing your health care and other services related to your health care. For example, we may use PHI to provide counseling to you. Or, we may disclose your PHI to other health care providers involved in your treatment, such as your family physician or another therapist.
Payment is obtaining reimbursement for your healthcare. For example, we will disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.
Health Care Operations are activities that relate to the performance and operation of our practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination.
II. Uses and Disclosures Requiring Your Authorization
We may use or disclose PHI for purposes outside of treatment, payment, or health care operations when your appropriate authorization is obtained. An “authorization” is written permission above and beyond the general consent that permits only specific disclosures.
You may revoke all such authorizations (of PHI or Psychotherapy Notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) we have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage; the law provides the insurer the right to contest the claim under the policy.
III. Uses and Disclosures with Neither Consent nor Authorization
Your therapist may use or disclose PHI without your consent or authorization when required or permitted to do so by law. The most common such disclosures is a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case.
IV. Your Rights
Right to Receive Confidential Communications by Alternative Means and at Alternative Locations: You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing a therapist.) On your request, we will send your bills to another address.
V. Effective Date and Changes to this Notice
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MIPS QUALITY MEASURES Tutorial!
All MIPS measures are reported once per year during the Diagnostic Interview. If you have been seeing a patient in the previous year and continue in the new year, you should perform a new 90791 in January.
In addition, every clinician who sees a patient for the FIRST time should perform her or his own 90791 visit for the patient at the start of treatment. This is true for new patients who are assigned or transferred to you from other clinicians. It also applies to any patients you have seen previously who have been re-referred for a new episode of care. This establishes your current and full understanding of the case before proceeding to ongoing psychotherapy or behavior management services.Therapists who are referred patients for capacity evaluation or neuropsychological testing services must still begin services by completing a 90791 and the required quality measures. This helps build a rationale for testing (or rules out the need for testing) at the current time.
Below are the MIPS Quality Measures. The acceptable “findings” (G codes) you may select, as well as practical tips on how to complete the work in our treatment setting, are provided for each measure.
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Measure 283: Dementia Associated Behavioral & Psychiatric Symptoms
A) Measure 283 Dementia Associated Behavioral & Psychiatric Symptoms
____ N/A patient not known to have a dementia diagnosis at this time.
_____ G9920 Patient carrying a Dementia Dx was screened NEGATIVE today for Activity Disturbance, Mood Disturbance, & Thought/Perceptual Disturbance.
______ G99919 Patient carrying Dementia Dx was screened POSITIVE today for Activity Disturbance, Mood Disturbance, &/or Thought/Perceptual Disturbance and Recommendations for patient management provided.
Please review the case while completing your Diagnostic Interview for any evidence of dementia diagnoses previously given in the medical record or observed in the course of your diagnostic interview. Even though we do not bill under a Dementia Dx (as dementia is never the focus of our direct care), many patients carry a previous Dx of Dementia. Our Diagnostic Interview form requires you to screen for activity disturbance, mood disturbance and thought/perceptual disturbance in all patients. It is very likely a patient with dementia referred to our services has some documentable disturbance in activity, mood and thoughts/perceptions in the past 12 months. When performing the 90791, you are being paid to make some helpful recommendations to the care team for patient management based on the specific disturbance. If the patient has no known Dementia Dx, select option “N/A.” If a patient with Dementia is NOT found to have any positive behavioral or psychiatric symptoms in the past 12 months, select G9920 and write “Not Applicable” in the open field requiring your recommendations for patient management. In most cases, a patient with Dementia will be found to have such symptoms in the past 12 months that impact their activity, mood, thoughts/perceptions. In these majority of the cases, select G9919 and then document one or two patient-specific recommendations for management.
- Examples of “activity disturbance”: agitation, wandering, eating or sleep problems, repetitive behavior, apathy, hyperactivity, social inappropriateness.
- Examples of “mood disturbance”: depression, anxiety, elation, irritability, lability.
- Examples of “thought/perceptual disturbances”: delusions, hallucinations, paranoia. Please reach out to patient's doctor for clinical support if you are not sure how to make recommendations for patient management.
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Measure 431: Unhealthy Alcohol Use Screening and Brief Counseling
HOW MANY TIMES IN THE PAST 12 MONTHS DID YOU HAVE MORE THAN 5 (men) or 4 (women) DRINKS IN A DAY? Patient classified as “unhealthy user” if the response is >/= 1 day in past 12 months.
_____ G2197 G9622 Patient not identified as an unhealthy alcohol user by systematic screener.
_____ G2196 G9220 G9621 Patient is identified as an unhealthy user and received brief counseling this visit.
_____ G2198 G9623 Patient not screened due to limited life expectancy, crisis situation, or other documented medical reason
This measure requires you to simply indicate whether or not you asked the patient the prompt above and if confirmed to be an unhealthy alcohol user, you then provide brief related counseling for minimum of 5 minutes. If male patients state they have had more than 5 drinks in a day at least 1 day in the past 12 months, they are positive for unhealthy alcohol use. Female patients should be asked “How many times in the past 12 months did you have more than 4 drinks in a day?” If they respond with 1 day or greater, they are positive for unhealthy alcohol use. If the patient is NOT identified as an unhealthy alcohol user by this systematic screener, then you select G2197,G9622. If the patient is identified as an UNHEATHLY USER of ALCOHOL, select G2196, G2200, G9621, and in this visit, you should perform 5-15 minutes of counseling in which you either: provide feedback on alcohol use and harms, identify high risk situations for drinking along with coping strategies, and/or increase motivation and develop a personal plan to reduce drinking. If the patient is not screened this visit due to limited life expectancy, crisis situation or some other documented medical reason, then select G2198, G9623.
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Measure 128: Body Mass Index (BMI) Screening and Follow-Up Plan
C) Measure 128 Body Mass Index
Score: ______Date Calculated:________Calculated By:________
Normal parameters: BMI > or = 18.5 and <25
_____ G8420 BMI w/in normal parameters, no f/up needed.
_____ G8417 BMI above normal, f/up plan noted as: ________________
_____ G8418 BMI below normal, f/up plan noted as: ________________
_____ G2181 No BMI documented due to pt refusal, hospice care, crisis situation, or BMI not appropriate to measure
[Calc Def: English Units: BMI = Weight (lbs) / [(Height (in)] 2 x 703]
You may obtain an official medical report on patient height and weight within the last 12 months from the facility chart, facility staff, or other medical record, but you may not utilize patient "self-report" of height and weight for this measure. Select one of the four G codes. If BMI is out of normal range, then you need to specify a follow up plan. Examples include education, referral to other provider such as dietician, PT/OT, pharmacological services, exercise or nutrition counseling.
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Measure 134: Screening for Clinical Depression and Follow-Up Plan
D) Measure 134 Depression Screen (e.g.PHQ9, GDS) Scale Used: _______ Score: _________
_____ G8431 positive screen for clinical depression, f/up plan noted as: _________________
_____ G8510 Negative screen for clinical depression, no f/up required.
_____ G8433 Screen not performed due to pt refusal, crisis situation, functional capacity limits accuracy of screen
Please utilize the most appropriate depression screen for each and every patient. Some clinicians will prefer to use the PHQ9, while others prefer the Geriatric Depression Scale, Cornell Scale, Beck, etc. Medicare simply requires that we use a "normalized and validated depression screening tool developed for the patient population in which it is being
utilized." The name of the age appropriate standardized depression screening tool utilized must be documented in the medical record, as well as the score. Coping.us provides you with the PHQ9 and the GDS. There are three G codes to choose from. If your depression screen is found to be positive (G8431), then you must also document your follow up plan by selecting one of the options provided in the drop-down box. Examples include a) additional assessment of depression, b) will provide ongoing treatment to reduce/relieve depressive symptoms, c) will complete suicide risk assessment, d) will refer to psychiatry/attending physician for pharmacological interventions. If the screen is negative, select G8510. If patient refuses to complete the screen, is in crisis or has functional capacity limits that would render your screening results inaccurate, you may select G8433 as your finding on this measure. IN 2021 & FORWARD, WE CAN NO LONGER OCUMENT SUICIDE RISK ASSESSMENT AS A FOLLOW UP PLAN TO A POSITIVE DEPRESSION SCREEN.
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Measure 226: Tobacco Use: Screening and Cessation Intervention
E) Measure 226 Tobacco Use Screen & Cessation Intervention
____ G9902 G9906 4004F Patient screened for tobacco use, identified as a user, & received 3-minute cessation counseling.
____ G9903 1036F Pt screen for tobacco use and is currently NOT a tobacco user.
____ G9904 4004F with 1P No tobacco use screen performed or f/up due to limited life expectancy or other medical reason
This measure is simple to report! It refers to any use of tobacco, but does not include nicotine patches or other addictive substances. This measure requires you to simply indicate whether or not you asked if the patient is a tobacco user and if patient is currently a user of tobacco in any form, then you select G9902/G9906/4004F and perform a three minute
"cessation counseling intervention" and/or recommend pharmacotherapy. The other two options include "patient screened and is not a tobacco user" (G9903/1036F) and "patient was not screened due to medical reason or limited life expectancy" (G9904/4004Fwith1P).
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Measure 181: Elder Maltreatment Screen and Follow-Up Plan (for patients 65 and older only)
F) For ages 65+: Measure 181 Elder Maltreatment Screen (Elder Abuse Suspicion Index)
____ G8733 Positive screen, f/up plan noted as: ________________________________
_____ G8734 Negative screen, no f/up required.
_____ G8535 Elder maltreatment screen not performed due to pt was in crisis situation during session or patient refusal to participate in screen & has decisional capacity for self-protection.
Using the EASI (Elder Abuse Suspicion Index) tool, please obtain yes, no, or cannot say responses on the 6 items. Like many of the other quality measures, your keen clinical judgment and decision making about what you do with the obtained information will be important. This measure has a strong potential for many false positives in the SNF and AL setting. In our unique treatment setting, it will be very common to have "yes" responses from many of our patients that in actuality do not constitute serious threats to the patient (e.g., many patients do rely on others for bathing or banking and many are often upset by the facility not getting the food they want, pain meds upon demand, etc.). Medicare simply wants us to be aware of the risk factors for elder maltreatment and to have a watchful eye as a healthcare provider. Like many of the tools used in PQRS data gathering, you do not report the specific findings from the EASI scale. You simply report one of the three available G codes. If you have a truly positive elder abuse situation (G8733), you must document the specific follow up plan (which 100% of the time means you will be notifying the facility staff who will be required to make a report to APS and other state authorities). If you have a negative screen, select G8734. If the patient is in emerging crisis during session or refuses to respond to the measure and has decisional capacity to self-protect, then you select G8535.
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Measure MBHR1: Anxiety Utilization of GAD-7
G) Measure MBHR1 Anxiety Screen Using GAD-7 Score: ______Date Measured: ________
____ PRO2000.4Y Patient was administered GAD-7
____ N/A Patient not given GAD-7 due to cognitive, visual, motor, reading, or language deficit.
Using the GAD-7 (Generalized Anxiety Disorder tool), measure the current level of anxiety over the past two weeks. Like other quality measures, your clinical judgment and decision making about what you do with the obtained information is important. Payers want us to address any and all symptoms that have the potential to make patients unhealthier both physically and mentally. There is no question that anxiety impacts the quality of life and health status of patients in a negative way. The overall impact of untreated anxiety on the health care system is enormous and is a costly burden to us as taxpayers.
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