What the insurance companies want.

Discussion by Dunlap & McDowell for 2-28-03 Pragmatics of HIPAA Training

Reviewing the conflicts between what most mental health professionals consider to be psychotherapy notes and what HIPAA defines as psychotherapy notes. (see Therapy Notes vs Clinical Record and The Contentious Matter of Psychotherapy Notes,) mental health professionals realize that this area is where we must draw clear boundaries in protecting client privacy.

The document in the box below illustrates the position taken by insurance companies concerning how psychotherapy sessions should be documented, with the clear implication that such documentation would be available for review by the insurance company. 

Note how far these requirements exceed even HIPAA requirements for documentation. Refer to the Guidelines Documents issued by the American Psychiatric Association. (Links below)

Guidelines for Clinical Documentation of Therapy Sessions

 General guidelines

Clinical notes for outpatient and inpatient therapy sessions serve to document not only the patient's clinical status and progress, but also serve to ensure that quality of care is adequate and payment is made for services provided. The record should include documentation that each therapy session was an active, directed process and that the therapist regularly took stock of specific clinically valid treatment issues. Clinical notes do not need to be lengthy. At a minimum, clinical notes should include:

    Date and length of therapy sessions

    Patient's current clinical status as it relates to diagnosis and as evidence by the mental status and physical status observations

    Clinically important objective events in the treatment setting or the patient's life (e.g., the therapists unexpected absence, or a death in the family)

    Documentation of practitioner/provider's efforts to obtain relevant information from other sources

    Collaboration with other practitioner/providers and providers

    Content of the therapy session (i.e., major themes discussed)

    Summary of the therapeutic intervention of the session

    Summary of an assessment of the patient's progress or lack of progress toward the treatment goals. Changes in diagnosis, DSM or ICD codes, functional status, etc. (e.g., the appearance of new symptoms, return to work, new medication)

    Treatment plan for the immediate future, and

    Medications (if any) being prescribed by the practitioner/provider, such as the name, dosage, instructions and any side effects that have occurred. The record should document as appropriate that noted positive benefits outweigh noted side effects.

    Notation that the patient has been fully informed and indicated an understanding of the risks and benefits of a new medication or therapeutic procedure

 Group, conjoint and family therapy

Clinical notes are required for each group, conjoint or family therapy session. Again, the notes need not be lengthy. The clinical notes should include:

    Date and length of therapy sessions

    Number of participants

    Relationship of the participants to the patient if it is conjoint or family therapy

    Content of the therapy sessions (i.e., major themes discussed)

    Summary of the therapeutic intervention attempted during the therapy session

    Summary of how the session has influenced the patient (or relevant significant others) as compared with the treatment goals, and

    Nature and degree of the patient's participation and response to the therapy session

 From the Regence BlueCross/BlueShield of Oregon "Behavioral Health BluePrint" (Nov. 2001) and the draft American Psychiatric Association "Resource Document on Documentation of Psychotherapy, October 8-9, 2001

Note that this “guideline” exceeds even HIPAA documentation criteria  substantially, and that it misrepresents the tone and concerns of the American Psychiatric Association Documents  to which it refers.

AMERICAN PSYCHIATRIC ASSOCIATION Documentation of Psychotherapy by Psychiatrists

AMERICAN PSYCHIATRIC ASSOCIATION Minimum Necessary Guidelines for Third-Party Payers for Psychiatric Treatment