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Physicians Order for Pcyhotherapy

  1. #1
    Default Physicians Order for Psychotherapy
    Medical Coding Books
    I work for an article 28 clinic and am reviewing our psychiatric charts. I would like to know how agency's handle their treatment plans and orders for psychotherapy sessions.

    If I read this correctly, the ordering MD must sign the treatment plans, this is then used to certify medical necessity and the number of psychotherapy sessions ordered.

    If a patient's order for psychotherapy comes from say their primary care MD, does that mean he should be signing off on my LCSW's treatment plans to certify medical necessity? If so, do we still need a separate order written every 90 days?

    Currently treatment plans for patients who get their orders from outside of our agency are not signed by the ordering MD. We only have a written order from the patient's primary care doctor and I am told that is all we need to certify medical necessity. I dont think this is enough to satisfy Medicaid guidelines. Thoughts?

    According to the Medicaid Article 28 Manual

    In addition to the items that must be maintained in the enrollee case record, as specified
    in this Manual, such case record must also include the following information at a

    1. A signed and dated treatment plan that includes, but is not limited to, theenrollee's diagnosis, the enrollee's treatment goals and the number of sessionsordered by the physician/psychiatrist. The physician involved in the treatment must sign treatment plans and, in doing so, is ordering the service and certifying the medical necessity of those services.
    2. Dated and signed progress notes for each visit/contact identifying the sessioncontent and duration, as well as changes in goals, objectives, and services. Theclinical person who provided the service must write such notes.
    3. Periodic assessment of enrollee's progress toward goal.
    Last edited by heatherwinters; 10-08-2009 at 10:57 AM. Reason: More information added.
    Heather Winters, CPC, CFPC

  2. #2
    Default Physician's Order
    Any thoughts on this would be greatly appreciated :-)
    Heather Winters, CPC, CFPC

  3. #3
    I'm not really sure what to say and It may be wrong, but I think that if a psychiatrist is not providing care then he shouldn't sign a treatment plan.

  4. #4
    Default Treatment Plan
    I guess specifically, the question would be, if the order for psychotherapy comes from a patient's primary MD, and not your in house psychiatrist, who signs the treatment plan other than the counselor? Treatment plans are supposed to be signed by an MD, how is this handled?
    Heather Winters, CPC, CFPC

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