E/M notes and psychotherapy notes

[usopen]

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When you code for E/M + add on psychotherapy (ex, 99213+90833), do you write notes for E/M and psychotherapy separately? OR do you just merge them into one note and have different parts dedicated to each section?

I understand that psychotherapy notes get treated specially by HIPAA so I wonder how everyone does this.

Thanks!

 

[Attending1985]

When you code for E/M + add on psychotherapy (ex, 99213+90833), do you write notes for E/M and psychotherapy separately? OR do you just merge them into one note and have different parts dedicated to each section?

I understand that psychotherapy notes get treated specially by HIPAA so I wonder how everyone does this.

Thanks!

I do one note with separate paragraphs addressing e/m and therapy. The coders are most I interested in me explicitly stating time spent on each.

 

[splik]

"psychotherapy notes" per HIPAA refer to process notes which are never part of the medical record and are not owned by patients. However, you still have to document that you see a patient for therapy in the medical record, which should include the type of the therapy, the exact duration of the therapy portion, the interventions provided, the diagnoses, and the plan. this is not a psychotherapy note. as mentioned above you may need to put start and stop times depending on how anally retentive your coders are.

if you search the forum you will see examples of how to document this. I know I provided examples somewhere.

 

[usopen]

I do one note with separate paragraphs addressing e/m and therapy. The coders are most I interested in me explicitly stating time spent on each.

Thanks for sharing!

 

[usopen]

"psychotherapy notes" per HIPAA refer to process notes which are never part of the medical record and are not owned by patients. However, you still have to document that you see a patient for therapy in the medical record, which should include the type of the therapy, the exact duration of the therapy portion, the interventions provided, the diagnoses, and the plan. this is not a psychotherapy note. as mentioned above you may need to put start and stop times depending on how anally retentive your coders are.

if you search the forum you will see examples of how to document this. I know I provided examples somewhere.

Thank you so much! I find this very helpful. Which part of the E/M note do you usually include this information? At the end? Associates with a specific problem on the problem list?

 

[usopen]

Now I understand better about these types of notes. If we are talking about progress notes for E/M and psychotherapy, they could be combined into one note. The true sense of psychotherapy notes are not the progress notes but an optional private note for the psychiatrist or the therapist.