Behavioral health treatment records must contain at minimum all the following elements (in addition to any state-required components):
All entries in the treatment record are legible to another person other than the writer, dated and signed/authenticated (including licensure and/or certification) by the rendering provider prior to submission of the claim.
Rendering provider requirements
Independently licensed in the state in which the provider is rendering and billing the services.
Rendering provider on the claim is the same individual that performed the service.
Provides services within the scope of their individual licensure.
Examples of appropriate licensed behavioral health provider types: Provider type is an appropriate licensed behavioral health provider (examples include Licensed Clinical Social Worker (LCSW), Licensed Marital and Family Therapist (LMFT), Licensed Psychologist (LP), Licensed Psychological Examiner - Independent (LPEI), Licensed Professional Counselor (LPC), Licensed Alcohol and Drug Abuse Counselor (LADAC), Advanced Practice Registered Nurse (APRN), Doctor of Medicine (MD), Doctor of Osteopathic Medicine (DO)).
Excluded provider types: Provider type is not an excluded provisional or trainee type (examples include Counselors in Training (CIT), Rehab Day Specialists (RDS), Licensed Associate Counselor (LAC), Licensed Master Social Worker (LMSW), Provisionally Licensed Psychologist (PLP)).
Member/Enrollee's name is documented on each page.
Date of service (DOS) is documented at the top of each note and no less frequently than on each page.
Mental health diagnosis listed meets criteria noted in the most current version of the Diagnostic and Statistical Manual of Mental Disorders and is consistent with presenting problems, symptom history, mental status examination, and other assessment data.
Type of service provided is documented.
Exact start and stop times of the service are documented.
Reason for service (problem statement) is documented.
Each service encounter is individualized to the member/enrollee and specific date of service.
Results of required screenings, assessments, or reassessments are documented.
Support for medical necessity that clearly outlines justification for frequency/intensity of requested services is documented.
Treatment plan requirements
Plan for ongoing treatment (i.e., plan for next sessions) is consistent with member/enrollee diagnoses.
Objective, measurable goals and estimated timeframes for goal attainment or problem resolution are included.
Includes a preliminary transition/discharge plan individualized to the member/enrollee.
Clear clinical/therapeutic interventions and member/enrollee response to the interventions are documented.
Interventions are clearly linked to the member/enrollee's goals, behavioral health needs, and diagnosis.
Interventions are related to evidence-based treatment.
Summary of progress or lack of progress toward identified goals, with care plan changed accordingly to meet the current need.
Discharge summary (if applicable): If applicable, discharge summary includes: summary of care, treatment, and services provided; member/enrollee's condition at time of discharge; rationale/reason for discharge; written discharge instructions including referrals, follow-up care, and medication regimen as applicable.