Revenue Cycle Insider

You can show providers the significance of thorough documentation by letting money talk.

Objectively, coding behavioral health shouldn’t be much different than coding any other category of diagnosis, but providers may struggle to get their behavioral health services paid.

Jamie Taylor, CPB, shared ways that primary care coders can strengthen their documentation practices to boost their revenue, with a focus on reporting behavioral health conditions, during her DOCUCON 2025 presentation “Beyond Anxiety: Stronger Behavioral Health Notes for Stronger Coding.”

Documentation Needs to Match the Moment

With their expertise and experience, coders help providers and entire practices bridge the gap from providing care to actually getting paid.

“We aren’t just coders, we aren’t just billers, we aren’t just  CDI [clinical documentation integrity] specialists. We are really the mechanism that helps keep revenue, helps keep charting, helps keep documentation, helps keep practices and providers out of hot water,” Taylor said.

Coders know what documentation they need to support their selection of the correct codes, but sometimes providers aren’t excited or even open to changing their ways. So, it may be helpful to remind providers that if they’re interested in receiving 100 percent of the available payment for the services they’ve rendered, they need to follow the current guidelines, policies, and procedures for documenting that care.

Primary care providers (PCPs) and practices especially need to stay on top of their documentation, because virtual medicine has allowed PCPs to provide care via different platforms, and coders are tasked with documenting many kinds of services and care.

“We’re in a new era of medical care. We have virtual platforms, we have telemedicine, we have  EMR [electronic medical records], we have remote monitoring systems; so, you know, we really have to change our mindset of how we used to practice medicine and how we’re going to practice it now, in 2025,” Taylor said. “And remember, this is the overarching rule for all documentation, not just behavioral health, but really for anything: If it’s not documented, it didn’t happen.”

This rule also applies to timelines: For compliant and accurate documentation, providers really need to attend to patients’ charts regularly, within a certain timeframe, so coders can do their jobs effectively. “It’s not OK for your charges to be submitted or your claims to be submitted to payers before that note is completed in your system,” she said. “We really have to change our mindset of how we used to practice and how we are going to practice within acceptable guidelines now.”

Put a Dollar on It

If you’re trying to educate providers about improvements they need to make to documentation but are receiving a lot of pushback or a lack of enthusiasm, try letting money talk, Taylor suggested.

“Show them specific examples of their documentation deficiency and then put a dollar amount on that potential loss,” she said.

For example, if an evaluation and management (E/M) level 4 visit, or a therapy visit, has an expected reimbursement of $124, then by seeing eight patients a day, you’d expect $992 a day. Without considering any other codes, including add-on codes, this single CPT^® code could bring in $4,960 a week.

But, if you aren’t coding to the highest levels of specificity and severity, and if you aren’t on board with what you need to drive your documentation completion and drive the billing and revenue cycle, then you really stand to lose a substantial amount of dollars, Taylor said.

“If you’re having issues in your practice, put pen to paper and put an amount out there to really show your providers, ‘If we don’t do this, then this is the amount of dollars we could potentially be earning or potentially looking at recouping,’” she said. Even if you’ve had the conversation before, sometimes it doesn’t hit home until people understand exactly how the bottom line is affected.

Establish and Maintain Policies and Procedures

You should create policies and procedures around documentation completion guidelines, and make sure you include timeframe for completion, Taylor said.

You can also incorporate continuing education about documentation completion and guidelines for annual training, like for compliance or patient privacy.

“Have [providers] sign off on it. Train them annually and track it. If you put a [performance improvement plan] PIP in place and somebody is on improvement because it’s a continual pattern, document that. Have those tough conversations and apply expectations to that,” Taylor said.

Conducting annual trainings can also be a good way to stay on top of any changes to codes, as well as federal or payer regulations.

For example, during the COVID-19 public health emergency (PHE), the Centers for Medicare & Medicaid Services (CMS) adjusted many guidelines around virtual or teletherapy, which has led to ongoing changes to how many services primary care providers offer, including behavioral health services, are delivered.

Both providers and staff responsible for revenue cycle management may still be figuring out how to document and code virtual services, like when a patient shows up on time, but connectivity issues compromise the appointment. Having policies and procedures in place can lessen the angst when needing to figure out how to get paid even if a visit doesn’t go quite according to plan.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor, AAPC