Mental Health Documentation Requirements

It is expected that patient's medical records reflect the need for care/services provided. The listing of records is not all inclusive. Providers must ensure all necessary records are submitted to support services rendered. They may include:

Check Brief Description
  Correct Beneficiary and Date of Service
  Relevant and/or current records from physician's office, e.g., office notes, history and physical, labs, etc. as supporting documentation of medical necessity for service provided
  Physician Certifications
  Physician or Non-Physician Practitioner (NPP) Order and/or Intent (*Note intent [i.e. progress notes] should be properly authenticated by ordering provider)
  Time based codes - Send documentation to support time spent and /or time frame. Example: Psychotherapy (Because time is indicated in code descriptor for psychotherapy CPT codes, it is important for providers to clearly document in patient's medical record time spent providing psychotherapy service rather than entering one time period including E&M service.)
  Documentation contains valid signature of every attendant and Physician (legible and complete)
  Documentation to support indications and/or criteria as specified in Local Coverage Determinations (LCDs), National Coverage Determinations (NCDs), or coverage article for service(s) billed, if applicable
  Advance Beneficiary Notice of Noncoverage (ABN), if applicable
  Completed Noridian Part B Signature Attestation Statement [PDF] or Signature Log for illegible signature, if applicable

 

Multiple CMS contractors are charged with completing reviews of medical records. See Identifying Which Entity Completed a Part B Claim Review for detailed information about each of these contractors.

Documentation Submission

Once a provider/supplier compiles all the necessary documentation, it is important to submit them to the appropriate contractor according to the request received. Select the request below to view the appropriate submission instructions.

View the Mental Health webpage for additional information and resources.

See also the Psychotherapeutic Services and Documentation Requirements webpage.

 

Last Updated Feb 08, 2019

Documentation Requirements Disclaimer

The documentation requirements contents/references provided within this section were prepared as educational tools and are not intended to grant rights or impose obligations. Use of these documents are not intended to take the place of either written law or regulations.

The listing of records is not all inclusive. Providers must ensure all necessary records are submitted to support services rendered.

Important that physician intent, physician decision and physician recommendation to provide services derived clearly from the medical record and properly authenticated.

The submission of these records shall not guarantee payment as all applicable coverage requirements must be met.