I have a therapist wanting to bill two individual therapies for back to back sessions (I do not have easy access to the start/stop times at the moment, but it was like 27 min for one and 30 min for other with only seconds separating the two visits (i.e. one may have ended at 9:26 and the other started at 9:27) where each patient was present for the other's session. I will put the notes below.
I have questions.
(Codes for review assigned by clinician -- 90832 with F41.1)
Met with Mr. H face to face today to provide CBT at the clinic. Mrs. H, his wife, was present per Mr. H's request.
Focus of the session:
Writer provided therapy to Mr. H focused on exploring barriers in successful communication within his relationship with his wife and the reason for Mr. H's emotional triggers and reactions. The benefit of this service was to draw the connection between thoughts, feelings, and behavior as it impacts their relationship as well as to point out Mr. H's role in managing his thoughts, feelings and symptoms. Writer used open ended questions to facilitate discussion and validated Mr. H's feelings. Mr. H expressed pride in how well his relationship with his wife is going well. He stated that his mother in law made up rumors about him behind his back that he had been unfaithful in his marriage and fathered a love child. He stated that he and his wife let the issue go and that it did not impact their trust in each other. Mr. H stated that he has been doing things for his wife to communicate his love and affection for her.
Individual symptoms/issues addressed:
Anger, communication
Goal from Treatment Plan:
Over the next 90 days, Mr. H will have 0 incidents of unsuccessful communication with his wife, as defined by arguing. This will be evidenced through self report.
Progress Towards Goal:
Maintained progress
Client Presentation:
Mr. H presented in a pleasant mood and engaged in session. He stated that his irritability and anger have been well managed this week. Mr. H showed insight into his symptoms and said they are being well managed at this time. Mr. H denied any new symptoms.
Plan/Next Steps:
Writer will meet with Mr. H on 7/26 at 9AM to work on communicating as a couple. Mr. H is to use coping skills until then and will track positive interactions with his wife.
(Codes for review assigned by clinician -- 90832 with F34.1)
Met with Mrs. H face to face today to provide CBT at the clinic. Mr. H, husband, was also present.
Focus of the session:
Writer provided therapy to Mrs. H focused on processing her symptoms of anxiety and depression as well as exploring barriers in successful communication within her relationship with her husband. The benefit of this service was to draw the connection between thoughts, feelings, and behavior as it impacts their relationship as well as to point out Mrs. H's role in managing her thoughts, feelings and symptoms. Writer used open ended questions to facilitate discussion and validated Mrs. H's feelings. Mrs. H stated that things have been going well since last session. She stated that she and her husband are getting along well and that there have been 0 arguments between the two of them. Mrs. H stated that she became upset earlier this week due to her mother accusing her husband of being unfaithful and fathering a love child with another woman. She stated that she practiced setting boundaries and letting the rumor go in one ear and out the other. She stated that this helped her.
Individual symptoms/issues addressed:
Anxiety, depression
Goal from Treatment Plan:
Over the next 90 days, Mrs. H will use coping skills and practice healthy communication skills with her husband and family. This will be evidenced through self and team report.
Progress Towards Goal:
Maintained progress
Client Presentation:
Mrs. H presented in a pleasant mood and actively engaged in session. Writer noticed that she continues to lose weight, which writer praised Mrs. H for. Writer discussed with Mrs. H about using coping skills and setting boundaries with other as needed. Mrs. H stated that she is using coping skills of doing nice things for her husband, talking to him about how she is feelings and making clear what she likes and dislikes.
Plan/Next Steps:
Writer will meet with Mrs. H on 7/26 at 9AM to help her process her emotions. She is to use coping skills until then.
Thank you in advance for any assistance you can provide.
I have questions.
- Is it appropriate to bill Individual Therapy for each patient? Why or why not?
- If it really is marriage therapy, can you bill Medicare/Medicaid 90847 - Family Therapy with Patient Present?
(Codes for review assigned by clinician -- 90832 with F41.1)
Met with Mr. H face to face today to provide CBT at the clinic. Mrs. H, his wife, was present per Mr. H's request.
Focus of the session:
Writer provided therapy to Mr. H focused on exploring barriers in successful communication within his relationship with his wife and the reason for Mr. H's emotional triggers and reactions. The benefit of this service was to draw the connection between thoughts, feelings, and behavior as it impacts their relationship as well as to point out Mr. H's role in managing his thoughts, feelings and symptoms. Writer used open ended questions to facilitate discussion and validated Mr. H's feelings. Mr. H expressed pride in how well his relationship with his wife is going well. He stated that his mother in law made up rumors about him behind his back that he had been unfaithful in his marriage and fathered a love child. He stated that he and his wife let the issue go and that it did not impact their trust in each other. Mr. H stated that he has been doing things for his wife to communicate his love and affection for her.
Individual symptoms/issues addressed:
Anger, communication
Goal from Treatment Plan:
Over the next 90 days, Mr. H will have 0 incidents of unsuccessful communication with his wife, as defined by arguing. This will be evidenced through self report.
Progress Towards Goal:
Maintained progress
Client Presentation:
Mr. H presented in a pleasant mood and engaged in session. He stated that his irritability and anger have been well managed this week. Mr. H showed insight into his symptoms and said they are being well managed at this time. Mr. H denied any new symptoms.
Plan/Next Steps:
Writer will meet with Mr. H on 7/26 at 9AM to work on communicating as a couple. Mr. H is to use coping skills until then and will track positive interactions with his wife.
(Codes for review assigned by clinician -- 90832 with F34.1)
Met with Mrs. H face to face today to provide CBT at the clinic. Mr. H, husband, was also present.
Focus of the session:
Writer provided therapy to Mrs. H focused on processing her symptoms of anxiety and depression as well as exploring barriers in successful communication within her relationship with her husband. The benefit of this service was to draw the connection between thoughts, feelings, and behavior as it impacts their relationship as well as to point out Mrs. H's role in managing her thoughts, feelings and symptoms. Writer used open ended questions to facilitate discussion and validated Mrs. H's feelings. Mrs. H stated that things have been going well since last session. She stated that she and her husband are getting along well and that there have been 0 arguments between the two of them. Mrs. H stated that she became upset earlier this week due to her mother accusing her husband of being unfaithful and fathering a love child with another woman. She stated that she practiced setting boundaries and letting the rumor go in one ear and out the other. She stated that this helped her.
Individual symptoms/issues addressed:
Anxiety, depression
Goal from Treatment Plan:
Over the next 90 days, Mrs. H will use coping skills and practice healthy communication skills with her husband and family. This will be evidenced through self and team report.
Progress Towards Goal:
Maintained progress
Client Presentation:
Mrs. H presented in a pleasant mood and actively engaged in session. Writer noticed that she continues to lose weight, which writer praised Mrs. H for. Writer discussed with Mrs. H about using coping skills and setting boundaries with other as needed. Mrs. H stated that she is using coping skills of doing nice things for her husband, talking to him about how she is feelings and making clear what she likes and dislikes.
Plan/Next Steps:
Writer will meet with Mrs. H on 7/26 at 9AM to help her process her emotions. She is to use coping skills until then.
Thank you in advance for any assistance you can provide.
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