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

There are no national policies regarding documentation guidelines for psychological services. In light of this, several Medicare carriers have outlined specific documentation requirements through their respective local medical review policies (LMRPs). The following list of elements is a sample of such requirements as they appear in various LMRPs. These are not exhaustive lists and do not guarantee that you will not be audited! Your best strategy is to locate a comprehensive policy for the carrier with jurisdiction in your area.

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
Presenting complaint
Background information and history of present illness
Social and Family History
Present evaluation
Clinical observations and detailed mental status examination
Assessment and recommendations including plan for future follow-up

90806 - Individual Psychotherapy
Type of therapeutic techniques and approaches used
List of general topics addressed
Risk factors
Briefly, how present session relates to therapeutic treatment goals

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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