Basics of documentation for Mental Health Specialty

Basics of documentation for Mental Health Specialty

Mental health billing documentation has specific responsibilities to perform in order to receive reimbursement from the Medicare program. Medical billers have to ensure that the claims submitted are true and accurate, while justifying the medical record documentation for billed services.

Mental health billing documentation is simple terms is the process of recording details about a patient and his illness right from his first visit to his progress and discharge. Always remember the great old saying, ‘If it isn’t written, it doesn’t exist.

The point to be made here is the need for clear, consistent documentation of procedures to ensure that a patient’s history is clearly recognized, within the treatment plan, the services given and the clinical changes that have taken place during the treatment. Mental health billing documentation should be done in a simple and easy to understand language, and should be for the long-term use of all the involved parties.

Keep in mind that without billing documentation, one cannot find a pattern. It is vital to ensure that billing documentation and record keeping is not disregarded due to focus on providing patient care.

In fact, documentation and record keeping are critical in order to maintain accountability and simplify coordination to develop services provided to the patients. In such a situation, proper mental health billing documentation should not be neglected. And if the in-house staff is falling short in performing those duties, you can assign the task to a specialized mental health medical billing company.

Accentuate Quality Billing Documentation

Poor mental health billing documentation can adversely impact the reimbursement process. You have to make sure that everyone in your facility comprehends the value of correct, legible and complete documentation. If not, it will be difficult to make a perfect or complete claim.

Documentation of every patient encounter should include:

  • Reason of the encounter and the history
  • Physical examination report and previous diagnostic test results
  • Assessment, clinical impression, and diagnosis;
  • Plan verification
  • Date and legible identity

In the billing and documentation process proper coding also plays a vital part. Most mental health clinicians want to spend their time and energy in providing the patient care possible. However, while doing so they are not looking into coding process, and stand to lose a lot of revenue due to billing and coding errors. Medisysdata with a team of experienced personnel can step in and take care of the tedious work of mental health billing documentation while you can get back to doing what you love.

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