Here are some documentation guidelines by trailblazer LCDs.
Section I: Psychiatric Diagnostic Interview Examinations (90801, 90802)
The medical records must reflect in legible form the elements outlined in the above description of the services and contain all of the following elements:
•Date.
•Referral source.
•Length of session (these are not timed codes, however, the standard length of time is generally considered to be between 45 minutes and one hour).
•Content of session.
•Therapeutic techniques and approaches, including medications.
•Assessment of the patient's ability to adhere to the treatment plan.
•Identity of person performing service (legible signature).
•For interactive therapy, medical record should indicate the adaptations utilized in the session and the rationale for employing these interactive techniques.
•For services that include an E/M component, the E/M services should be documented.
•Multiaxial diagnoses.
Section II: Psychological and Neuropsychological Testing
The medical record should include all of the following information:
•Reason for referral.
•Tests administered, scoring/interpretation and time involved.
•Present evaluation.
•Diagnosis (or suspected diagnosis that was the basis for the testing if no mental illness was found).
•Recommendations for interventions, if necessary.
•Identity of person performing service.
Section III: Psychotherapy Services
The medical record must indicate in legible form, the time spent in the psychotherapy encounter and the therapeutic maneuvers such as behavior modification, supportive interactions and interpretation of unconscious motivation that were applied to produce therapeutic change or stabilization.
All the following elements should be contained in or readily inferred from the medical record:
•Type of service (individual, group, family, interactive, etc.).
•Content of session.
•Therapeutic techniques and approaches, including medications.
•Identity of person performing service.
•For interactive therapy, the medical record should indicate the adaptations utilized in the session and the rationale for employing these interactive techniques.
•For services that include an E/M component, the E/M services should be documented.
•Group therapy session notes can be organized according to the general session note guidelines for individual therapy appearing above, or the clinician may elect to use the following group note format:
◦One group note that is common to all patients, documenting date, length of time for each session, along with key issues presented. Other group members' names should not appear in this note.
◦An additional notation or addendum to the group note, for each patient's record commenting on that particular patient's participation in the group process and any significant changes in patient status.
Section IV: Pharmacologic Management of Psychiatric Illness (90862, M0064)
Patient records for pharmacologic management code 90862 should include or be able to be inferred by a trained professional, in legible form, all the following information in each note:
•Date and diagnosis.
•Current symptoms and problems.
•Problems, reactions and side effects, if any, to medications and/or ECT.
•Description of optional minimal psychotherapeutic intervention, if any.
•Reasons for medication adjustments/changes or continuation.
You can also check out this trailblazer site:
http://www.trailblazerhealth.com/Tools/LCDs.aspx?ID=2621&DomainID=1
'From there you can search the specific CPT codes for additional guidelines.
Hope this may help.
There is also a coding book specifically for Behavioral Health that is very helpful.
