Documentation Is Good Medicine
Recent audits of medical records have brought to light the variability with which psychiatrists and other mental health clinicians document their services. Although there are no national guidelines addressing what information is required for documentation of psychiatric services, it is clear that adequate documentation of services is essential—an appointment book is not sufficient.
When determining what to document, psychiatrists should consider the many functions of documentation, including the following:
| 1. | Documentation contributes to good care. Clear, concise recording of the when, what, and why of services you provide to patients is an intrinsic component of good care and good medicine. | ||||
| 2. | Documentation is your best protection against audit liability. | ||||
| 3. | Documentation protects you from accusations of malpractice. | ||||
| 4. | Documentation gets you paid. Documentation is the basis for selecting procedural codes that facilitate reimbursement. Payers must be able to demonstrate that the services for which they pay were, in fact, received by the beneficiary and that those services were medically necessary and consistent with the benefit package. | ||||
APA members can direct CPT coding and documentation questions to the APA CPT Coding Service, which can be reached by e-mail at [email protected] or fax at (703) 907-1089.
