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Documentation As a general rule, it is necessary to keep careful records on Medicare beneficiaries. Post-payment audits are common and psychologists must be prepared to document that they followed Medicare rules and that the services were "reasonable and necessary." Medicare does not pay for routine services (preventive or screening) so documenting presenting symptoms is important. As mentioned in other sections, documentation of circumstances surrounding non-collection of copayments and documentation regarding consultation are also very important.
Basic Requirements The most basic element for all documentation is that is must be LEGIBLE. You must also be sure to have the appropriate patient and provider identifiers, the date, diagnoses, and service provided (CPT code). In addition, listed below are elements for two specific types of services.
90801 - Psychiatric Diagnostic Interview Examination
90806 - Individual Psychotherapy The American Psychological Association (APA) has also developed Record Keeping Guidelines that can be found on our website at: http://www.apa.org/practice/recordkeeping.html, although these are generic in nature rather than specific to Medicare. |
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