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Auditing Psych notes

  1. #1
    Default Auditing Psych notes
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    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?

  2. #2
    Location
    Indianapolis
    Posts
    187
    Default 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
    Chandra L. Stephenson, CPC, CIC, COC, CPB, CPCO, CPMA, CPPM, CRC, CCS, CPC-I, CANPC, CCC, CEMC, CGSC, CFPC, CIMC, COSC
    2012-2013, 2016 President, AAPC Indianapolis Indiana Chapter
    2013-2015 AAPC National Advisory Board Member
    chandra.stephenson@gmail.com

  3. #3
    Location
    Ellenville, New York
    Posts
    1,176
    Default We audit, but not all notes
    Quote Originally Posted by 1073358 View Post
    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.

  4. #4
    Location
    Louisville, KY
    Posts
    1,101
    Default
    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).
    Last edited by kevbshields; 02-11-2010 at 09:28 AM.

  5. #5
    Default
    Quote Originally Posted by 1073358 View Post
    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.

  6. #6
    Default
    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.
    Donna E. Young, CPC

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