Wiki Auditing Psych notes

[1073358]

I am curious if we fit in the norm of psych offices or if we are different. How many of you actually review psych note documentation before billing to ensure that it supports the code the dr wants to bill?
On your psychotherapy notes, do your providers specifically list what type of therapy they do, or is it just inferred from the body of note?

 

[clsteph1]

Auditing Psych Notes

We do audit our psych notes. We use the CPT Handbook for Psychiatrists to help establish the criteria we required to be included in the documentation.

Hope this helps!
Chandra

 

[MnTwins29]

We audit, but not all notes

I am curious if we fit in the norm of psych offices or if we are different. How many of you actually review psych note documentation before billing to ensure that it supports the code the dr wants to bill?
On your psychotherapy notes, do your providers specifically list what type of therapy they do, or is it just inferred from the body of note?

We do occasional audits on our psychiatric practices, but random audits - not before sending out every claim.

We use a pre-printed form that includes a section on indicating the type of treatment performed. Sometimes that works, sometimes it is left blank. If it is and the type of treatment is not clearly documented elsewhere, we will provide an education session (along with other coding education) on that part of the audit to the provider.

 

[kevbshields]

All psych notes are abstracted by coding professionals prior to any bill leaving the house. There is a combination of providers who may or may not state the type of service performed. With as many psych providers as we have, it is difficult sometimes to narrow down the exact service some supply to patients. With that being said, a psych coder should have the ability to discern one service type from another--although there is always "gray" in this speciality (in my opinion).

 

[srswenson]

I am curious if we fit in the norm of psych offices or if we are different. How many of you actually review psych note documentation before billing to ensure that it supports the code the dr wants to bill?
On your psychotherapy notes, do your providers specifically list what type of therapy they do, or is it just inferred from the body of note?

I look at each note to verify the start/stop time is listed correctly for all therapy and 90805 notes. Our providers are usually great at choosing the correct codes, so that really helps as well. It also is necessary to review to make sure 90846 is billed vs. 90847 etc.

 

[deyoung]

I also used the CPT Handbook for Psychiatrists and Coding & Payment Guide for BH to estabilish criteria for auditing psych. We do random audits - pre & post billing. We have an EMR that lists the type of note at the top.