Behavioral Health Notes and Addendums

Kristen Bensel

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I am looking for some help with some supporting documentation and or thoughts from other coders that have worked in the behavioral health arena for a while.
Since I am new to the behavioral health arena, it is hard to find rules and guidelines for documentation requirements that reference behavioral health notes. For example, we have a clinician that is struggling with hitting all of the points that Medicare deems needs to be met in the note to support Psychotherapy codes. The question was raised that "well can we just add an addendum to add the information that is needed to support the code?"
I know that there are rules and guidelines for some things like :confused:time coding that indicates that a time spent face to face with a patient must be in the original note, can not be added as an addendum... does anyone have any suggestions of where I might find supporting documentation stating that to support psychotherapy codes the information must be in the original document, not added in an addendum?

Any help is greatly appreciated!
Thanks!
Kristen
 

Kristen Bensel

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Pilot rock, OR
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Thank you so much! I appreciate the quick response. This is such a different arena that it amazes me that there isn't so much guidance... at least not that isn't easy to find. :)
 
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