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Thread: Medicare doc requirements

  1. #1

    Default Medicare doc requirements

    AAPC: Back to School
    For psychotherapy Medicare requires the following documentation.
    # Date
    # Name
    # Type of service (individual, group, family, interactive ect)
    # Length of session (start and stop times)
    # Reason for encounter and pertinent interval history
    # Pertinent themes discussed and appropriate high risk factors
    # Content of session
    # Therapeutic techniques and approaches, including medications
    # Progress or regression
    # Changes in treatment plan
    # Diagnosis
    # Expected treatment outcome on a periodic basis
    # Identity of person performing service.
    # For interactive therapy indicate the adaptations used in the session and rationale for employing these interactive techniques
    # For services that include an E/M component,the E/M services should be documented.

    My question is, when we have to submit information to Medicare to prove that services were medically necessary, do we send all the information above? Isn't the "content of session" not subject to release? How have you handled this? Trying to make sure we are HIPPA compliant and Medicare compliant. It is definitely a tight rope.

  2. #2


    the only thing listed you dont have to send would be the really personal info.. ie. dream details, sexual abuse, etc etc. The rest needs to go to prove the service

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