Diagnosis & Medical Necessity
This is the label we assign based on a client’s symptoms
What is a diagnosis?
The most common note format and an alternative to DAP notes
What is a SOAP note?
Code for 60-minute therapy session.
What is 90837?
This happens when a clinician continues the same diagnosis and treatment approach for long periods without any documented reassessment.
What is failure to reassess / lack of re-evaluation over time?
Talking about a client in a public place where others can hear is a violation of what?
What is confidentiality?
This DSM diagnosis is meant to be short-term and tied to a stressor
What is Adjustment Disorder?
The work you do in session should clearly relate back to this piece of documentation.
What is the treatment plan?
Code for a 30 minute therapy session
What is 90832?
When a clinician’s notes repeatedly show little to no change in symptoms, goals, or interventions over time, this may suggest what broader concern?
What is lack of clinical progress or lack of updating over time (a.k.a. a stagnant chart)?
During a session, a client shares information that raises reasonable suspicion of child abuse. What is the clinician legally required to do?
What is making a mandated report?
This must be present (beyond symptoms alone) to support most mental health diagnoses for billing
What is functional impairment?
A note describes the client’s feelings in detail but does not describe clinician actions. What is missing?
What are interventions?
This add-on code is used when communication is more complex than usual.
What is 90785 (interactive complexity)?
Using the same note wording repeatedly is called this.
What is copy-paste documentation (also called record cloning)?
A client’s symptoms have improved significantly and they no longer meet full diagnostic criteria.
What should you consider doing?
What is updating or changing the diagnosis?
If a client’s symptoms significantly change, you should do this to their diagnosis
What is reassess or update the diagnosis?
A clinician documents “within normal limits” for all areas of the Mental Status Exam across multiple sessions. However, elsewhere in the notes, the client is described as having severe depression, low energy, and difficulty functioning.
What is inaccurate or contradictory documentation?
Codes like 90785 (interactive complexity) cannot be billed alone and must be used with this type of primary service code.
What is a base code?
A clinician bills appropriately for session time, but fails to document key elements like interventions or clinical decision-making. From an audit perspective, what is the issue?
What is that the service cannot be validated without sufficient documentation?
A client's partner calls to confirm the client's appointment time, stating they “just want to help keep them organized.” What should the client consider before confirming?
What is whether the client has given permission to share scheduling information?
A client has been diagnosed with Adjustment Disorder for 2 years with ongoing therapy. What is the main clinical concern?
What is lack of medical necessity / inappropriate long-term diagnosis?
A clinician copies the same detailed MSE across multiple clients, even though they present with different mood, affect, and functioning concerns.
What is lack of individualized documentation?
A clinician is unsure whether a session qualifies for 90837. What is the most important factor in making that decision?
What is whether the documentation supports the time and complexity of the service?
A clinician’s notes consistently describe every session as highly complex, emotionally intense, and requiring extensive intervention, with no variation across clients or sessions.
What is upcoding?
A clinician continues weekly therapy with a client who reports only mild stress, shows minimal impairment, and has had no significant changes in symptoms or treatment over several months. What is the most important question the clinician should be asking before continuing to bill sessions?
What is whether ongoing treatment is medically necessary?