Notes not individualized enough - 90833

[the5thelement]

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A friend of mine is having problems with Blue-cross paying for 90833. He is providing supportive psychotherapy
and documenting as such
but they have been telling him the notes are not individualized enough . He is at a loss to understand what this means.
Is the insurance company dictating what type of notes the psychiatrist writes? Does any one else have a similar problem?

 

[AD04]

Would you mind sharing how your friend documents the psychotherapy portion? Does he mix it up with no psychotherapy and 90833 and 90836 and maybe even 90838 across his patients? My guess is the insurance thinks he is including a standard template sentence across all of his patients without psychotherapy being done.

I haven't encountered this problem yet but I include bits about patient's work and relationships and treatment goals and homework (if I assign any).

 

[Sushirolls]

Need some excerpts of what has been documented and how and where. Or even tweak them to get the gist across for us in SDN land to chew on.

A lot of the ARNPs and older MDs in my local area when I acquire records, simply checking a box and bill, but nowhere can I find anything of support of what was done. A lot of the older MDs have hand written notes, and I can't glean anything from them. So if this friend is actually documenting something worthwhile that is concerning.

I've thought about doing a hand written note system myself, but I've seen my product - and I can't read even my own written notes!

 

[the5thelement]

"therapy content/clinical summary - Pt was educated about nature of illness, symptoms,course of illness and ways to treat and deal with unwanted consequences of illness on pt, patients relationships, work and functional abilities.
Supportive therapy focused on improving self esteem, ameliorate symptoms by being mindful, and to maximized patients adaptive capabilities by encouragement about returning to work, education, guidance and reassurance. Nature of relationships and emotional responses or behaviors examined to help pt become aware of"

 

[AD04]

The above reads like a standard template. Some (most?) insurance companies have no problem reimbursing based on that. I've seen people get reimbursed based on sparser documentation for psychothearpy. But BCBS is trickier to work with, to the extent that in the previous state I worked at, few psychiatrists accepted that insurance. Your friend can either drop BCBS or start "individualizing" the psychotherapy portion.

In my psychotherapy part, the reader has an idea who the patients are and how they're functioning at work / school / life and what their family and relationships are like and their short-term and long-term goals in life and frustrations. And for example, if patient wants to have better sleep and we're doing CBT-i, homework part may show patient is to start a sleep diary and keep it updated daily. Then in the next visit, I'll update whatever changes occurred (e.g. relationships, homework assigned, etc.) I mainly do this because I cannot remember the details about each patient or what we discussed and knowing these details help me better engage the patient during my sessions.

 

[calvnandhobbs68]

The above reads like a standard template. Some (most?) insurance companies have no problem reimbursing based on that. I've seen people get reimbursed based on sparser documentation for psychothearpy. But BCBS is trickier to work with, to the extent that in the previous state I worked at, few psychiatrists accepted that insurance. Your friend can either drop BCBS or start "individualizing" the psychotherapy portion.

In my psychotherapy part, the reader has an idea who the patients are and how they're functioning at work / school / life and what their family and relationships are like and their short-term and long-term goals in life and frustrations. And for example, if patient wants to have better sleep and we're doing CBT-i, homework part may show patient is to start a sleep diary and keep it updated daily. Then in the next visit, I'll update whatever changes occurred (e.g. relationships, homework assigned, etc.) I mainly do this because I cannot remember the details about each patient or what we discussed and knowing these details help me better engage the patient during my sessions.

Yeah it's gonna be super insurance dependent I feel. I've seen therapists get away with writing much less for 90837s for literally YEARS of weekly/biweekly therapy. However, even their 1-2 lines are more individualized to what they actually talked about during that session. Your friend might be able to start by just varying the content of each one. For instance, my 90833 template is basically just a plug and play of different therapy techniques and I just choose the couple we talked about/worked on each visit, then add a little blurb about what specifically we did (ex. thoughts/emotions/behaviors-> performed thought mapping around X situation, identifying emotions and resultant behaviors that occurred).

 

[clausewitz2]

I generally name a specific modality, a specific technique or two, and something about the content of that particular appointment.

Eg.

'... brief psychotherapy was performed in a GPM framework focusing on promotion of positive identity and ego strength, with special attention to difficulties in intimate relationships/workplace difficulties/academic struggles/whatever. Also rehearsed use of DBT skills, specifically coping ahead/DEAR MAN/your favorite goofy mnemonic.'

 

[NickNaylor]

No idea what the issue is with your "friend," OP, but my documentation strategy is similar to @clausewitz2's above. Here's the exact template that I use when I bill psychotherapy add-ons to my progress notes:

In session today, [2-3 sentence summary of what was discussed]

Treatment Goals: [uses a drop down list of generic goals, e.g., "decrease frequency and duration of depressed mood states"]
Treatment Objectives: [uses a drop down list with slightly more specific treatment outcomes, e.g., "decrease dependence on psychotherapy," "improve social network," "return to work," etc.]
Therapeutic Modality: [uses a drop down list with common modalities]
Progress: [drop down list - good/fair/improving/poor]
Prognosis: [drop down list - good/fair/improving/poor]
Face-to-face time with patient in psychotherapy: *** minutes

I've never had any complaints from our billing people when using this template, and I don't write all that much in the "narrative" portion of the note. Takes about 2 minutes to fill out. This is what our billing people have told us is what is expected for Medicare billing, but obviously private insurers may have different expectations.