Misery or Mastery: Documenting Medical Necessity for Psychotherapists

  • Dates: Friday, October 20, 2023; 10am-5:15pm EST (Find the time for your location)
  • Instructor: Beth Rontal, LICSW
  • Location: First Parish, 50 Church Street in Waltham, MA and Live on Zoom (synchronous)
  • Credits: 6 CEs

Description

Documenting psychotherapy is done to summarize services provided to many audiences who have access including clients, payors, and potential legal situations that may occur. It is necessary for professional, legal, and ethical standards. Since psychotherapy is covered by medical insurance, the gold standard for documentation is now based on the need to satisfy insurance company requirements. The most rigorous standards for clinical documentation are Federal, which is why most third-party payors base their requirements on Medicare standards. That standard involves justifying the need for services conceptualized as “medical necessity.” A fundamental feature of medical necessity is part of a “Golden Thread.” When the Golden Thread is employed, each element of the therapeutic process is clearly documented so that the connection between all aspects of clinical work flows logically within each document and from one document to the other. The criteria for a client needing services and the Golden Thread work together to justify medical necessity. Best practice documentation includes the clinician’s voice in a succinct narrative that makes clear how they conceptualize the treatment while also utilizing templates to facilitate ease of documenting what is needed.

The Goal
Good documentation helps organize clinical thinking. Progress notes, treatment plans, case and collateral contact notes, discharge and diagnostic summaries can be done quickly and efficiently and provide a vehicle for formulating and reflecting on high quality clinical work rather than being a detour or afterthought. Good documentation supports good clinical practice, facilitates getting authorizations, and helps mental health professionals and clinics pass insurance audits. When practitioners are skilled at documenting their work there is a reduction in work related anxiety, increased productivity, and increased job satisfaction. Beth will simplify clinical documentation by teaching her effective, efficient, and distinct procedure, which result in medical records that are clear, compliant, and clinically useful. 

The Process
Through lecture, group discussion, case examples, and questions and answers, you will learn the “formula” to translate your clinical intuition into the behavioral language required for medical record writing. Based on a videotaped interview between a client and therapist, you will practice composing the two main documents therapist write most often: the treatment plan and progress note. 

The Result
You will be able to apply this process to whatever documentation system you use. The result is increased accuracy and efficiency, a reduction in anxiety and procrastination, and the satisfaction that your documentation will contribute to the high quality of care you provide. In addition to meeting standards of care, you will notice a reduction in time spent writing paperwork. 
 

Instructor

Beth Rontal, LICSW is a nationally recognized and engaging speaker on mental health documentation for private practice clinicians and those working in agency behavioral health settings. She mastered her teaching on documentation with thousands of hours supervising and training both seasoned professionals and interns when supervising at an agency for 11 years. Beth was instrumental in developing the clinic’s first electronic documentation system which significantly reduced documentation time and errors. After the implementation of this system, the transformation from error laden to accurate record keeping saved the clinic thousands of dollars, reduced time spent writing notes, which enabled clinicians to see more clients without spending more time working. Beth’s training empowers clinicians, reduces anxiety about documentation, and furthers professional integrity. It simplifies the documentation process by systematically linking effective documentation to quality care. Her process helps clinicians to pass audits and protect income. Beth writes blogs on clinical documentation, co-chairs the NASW MA Private Practice Shared Interest Group, and has a private practice in Brookline, MA specializing in working with people who struggle with emotional eating.

Outline of Topics

  • How to write documentation to meet the needs of multiple audiences
  • Defining the “Golden Thread” and how it relates to medical necessity
  • The treatment plan “formula” that implements that Golden Thread and justifies medical necessity
  • How and why to operationalize the presenting problem using behavioral language with case example
  • Creating a clear connection between the problem, goals, objectives, interventions, and progress
  • Writing a session note that justifies medical necessity using behavioral language and the “golden thread” with case examples
  • Maintaining client confidentiality
  • How to document changes in treatment using the session note

Learning Objectives

Attendees will be able to:

  1. Describe several specific details needed in clinical documentation for writing successful treatment plans, session notes, case/collateral contact notes, discharge, and diagnostic summaries.
  2. Demonstrate how to translate clinical work into behavioral language required by insurance companies.
  3. Define the “Golden Thread” to justify medical necessity.
  4. Identify red flags and that could trigger an audit, incur an insurance recoupment, and lead to legal problems, and how to avoid them.
  5. List a minimum of three pros and cons of using paper notes vs. an electronic medical record.

Schedule

  • 9:30am to 12pm
  • Break
  • 1pm to 3pm
  • Break
  • 3:15pm to 5:15pm

Cost

  • Individual Registration: Regular Rate—$145; Early Bird Rate—$125
  • Early Registration Deadline: September 15, 2023
  • NEAFAST Member Rate: $120; Student Rate: $75
  • Black Therapists Rock, National Association of Black Counselors and all BIPOC clinicians may access an Equity Rate of $100.
  • Please contact us for discount codes. No application is required.
  • 6 CEs will be available for eligible professions at an additional cost of $20 paid upon registration.

Location

The event will be held live on Zoom.

Registration Instructions

Payment options include online registration with payment using PayPal as a conduit to your credit card or a PayPal account. You may also register online and mail a check with a note indicating what program the payment is for. If you are mailing payment, please note that your space is not reserved until we receive it.

Email acknowledgments will be sent to confirm receipt of online registrations only. An email will be sent a few days before the start date of the event with details about your program.

Workshop CEs

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Participants MUST attend 100% of the program to earn the 6 CEs approved for eligible professions. Within a week of the completion of the event, access will be given to participants who completed the workshop and paid for CEs to complete a course evaluation online and download their CE certificate.

  • Therapy Training Boston is approved by NBCC as an Approved Continuing Education Provider, ACEP No. 6707 for Mental Health Counselors. Programs that do not qualify for NBCC credit are clearly identified. Therapy Training Boston is solely responsible for all aspects of the programs.
  • Application for social work continuing education credits has been submitted.
  • Application for psychology work continuing education credits has been submitted.
  • Application for certification by the New England Association for Family and Systemic Therapy (NEAFAST) on behalf of the Massachusetts Board of Registration of Allied Mental Health & Human Services Professions for LMFT professional continuing education work has been submitted.
  • This webpage will be updated when approvals are processed. Please contact us for the status of CE approvals.

Read detailed information about CEs here.

Target Audience

This learning event is designed for helping professionals including, but not limited to, social workers, psychologists, mental health counselors, and marriage & family therapists. We designed the learning methodology to further develop beginning and intermediate professionals learning to use psychosocial support as a socially just practice. Advanced practitioners may attend the workshop in order to deepen their practice in direct service, supervision, and teaching roles. People who attend from professions other than those we are able to provide CEs for may request a Certificate of Attendance.

Cancellations and Refunds

No refunds are available for cancellations by participants regardless of the reason or time frame.

If participants cancel 30 days or more prior to the event beginning, they may apply the fee to a future program. Workshops may be cancelled by Therapy Training Boston if minimum enrollment requirements are not met or in the case of other unexpected circumstances. If this occurs, a full refund will be provided.

Additional Information

Course content level: This workshop will provide important information for clinicians who are at an introductory or intermediate level of knowledge about working with grief and traumatic loss. Advanced practitioners are welcome to attend the event to deepen their knowledge of the subject for practice, supervision, teaching, and administrative roles.

Target Audience: This offering is relevant to all helping professionals including but not limited to social workers, mental health counselors, psychologists, marriage & family therapists.

Commercial support and conflicts of interest: There is no commercial support for this program.

Policies

For all event policies read this, detailed CE information here.