Appropriate Documentation Supports Ethical Billing, Meeting Medical Necessity Criteria

Appropriate documentation of treatment services supports ethical billing, helps providers meet medical necessity criteria, and improve patient outcomes.

On Saturday at the Rocky Mountain Symposium for Addictive Disorders, David Nefussy and Lisa Blanchard, LMHC, who respectively are the vice president of business development and chief clinical officer for Spectrum Health Systems, presented a session on the alignment of best practices and documentation with managed care requirements.

Recently, Nefussy and Blanchard spoke with Addiction Professional by email to discuss skills needed to ensure appropriate documentation, tools that reduce risks for client care and clinical practices, and keys for aligning clinical practices with a managed care environment and value-based care.

Editor’s note: This interview has been edited for length and clarity.

Addiction Professional: What skills/knowledge are necessary for ensuring appropriate documentation that supports ethical billing and meets the criteria for medical necessity?

Nefussy and Blanchard: Providers should prioritize accurate and comprehensive clinical documentation that supports the services provided. This includes utilizing health records with prompts for assessments and note templates, documentation of the accurate time in/time out for each session, and progress toward treatment plan goals. Concurrent documentation and workflows, which allow for immediate documentation, support this effort.

AP: What tools should readers know about to help reduce risk both for client care and their clinical practice?

Nefussy and Blanchard: Risk management practices such as internal audits, coding reporting, and chart review can support risk reduction for a practice or an organization. An integrated care team approach that involves a broader care team to help support client care can provide the necessary supports to reduce individual client risks. However, documentation must reflect this integration and efforts in care coordination to be effective.

In short, the clinical record should clearly tell both the story of the treatment episode, but also clearly document with appropriate releases of information the integration of a full care team to support clients’ individual needs. “If it is not documented it wasn’t done.”

AP: What are some keys for aligning clinical practices with a managed care environment and value-based care? What are some common mistakes and/or pain points in this area?

Nefussy and Blanchard: Providers should ensure that they align their billing system or electronic health/medical record with the appropriate CPT codes they use when treating clients. In short, to make sure that they do not up-code—use 90832 as appropriate in lieu of 90834 unless they ensure doing the time allotment associated with the service code.

Likewise, they should consider consulting with a billing and coding specialist to make sure their record keeping aligns with the compliance expectation of the Centers for Medicare and Medicaid (CMS) and other payers. Providers have a tendency—primarily due to time constraints and, quite frankly, administrative laziness—to replicate treatment records. It is critical that providers note the goals and the outcomes individually for each client. Auditors and specialized investigative units (SIU) look for trends, and treatment records are easy to identify when duplication of records from one client to another is done.

Finally, it is imperative that providers regularly update their pay-scales/rates they bill. Payers—in particular, those in the public forum—at minimum should update their reimbursement annually. Therefore clinicians should always allow for at least a 10% rate enhancer beyond the highest payer to ensure full reimbursement for a service is received. Most contracts have language that will note compensation from said payer will equate to “payment shall be the lesser of: provider’s customary charge or the fee per the standard agreement.” In other words, if you bill less than the allowed amount per the agreement, you will be reimbursed accordingly.

AP: Is there anything else you would like to mention that we have not touched on?

Nefussy and Blanchard: Individual providers not yet associated or contracted/linked to various groups, accountable care organizations, or medical practices may want to look into aligning with such practices. As more and more payers look to medical behavioral integration (MBI), integrated behavioral healthcare blends care in 1 setting for medical conditions and related behavioral health factors that affect health and well-being. Integrated behavioral healthcare, a part of “whole-person care,” is a rapidly emerging shift in the practice of high-quality healthcare. It is a core function of the “advanced patient-centered medical home.”

Integrated behavioral health care is sometimes called “behavioral health integration,” “integrated care,” “collaborative care,” or “primary care behavioral health.” No matter what one calls it, the goal is the same: better care and health for the whole person.

Providers practicing integrated behavioral healthcare recognize that both medical and behavioral health factors are important parts of a person’s overall health. Medical and behavioral health clinicians work together as a team to address a patient’s concerns. Care is delivered by these integrated teams in the primary care setting unless patients request or require specialty services. The advantage is better coordination and communication, while working toward one set of overall health goals.

In order to accommodate this, most behavioral providers who previously may have worked in a private practice or now beginning to co-locate within a medical group or community health center previously may have been called upon simply to provide a behavioral health assessment are now being made part of the whole treatment team. This is a change that is being spearheaded by both CMS and the managed care industry in which treatment of the whole person is a preferred treatment modality.

Reference

Nefussy D, Blanchard L. Aligning clinical best practices and documentation with managed care requirements for improved client care. Presented at: Rocky Mountain Symposium on Addictive Disorders. Aug. 5-7, 2022. Denver, Colorado.