Clinical Documentation and Medical Necessity

Who should take it

Clinicians, supervisors, case managers, direct-care staff who write notes, and billing and quality staff who review documentation.

National course on documentation principles. Medicaid programs, Medicare contractors and commercial plans each have specific documentation, signature, time and treatment plan rules, and state licensing rules add their own. Follow your organization's documentation policy for the payers you bill.

What employees will learn

• ✓Explain why accurate, timely documentation matters for care, continuity and payment.
• ✓Describe how medical necessity is established and documented in behavioral health.
• ✓Write assessments and individualized treatment plans with measurable goals.
• ✓Write progress notes that link to the plan, use objective observations, and describe functional status and response.
• ✓Make late entries, amendments and corrections correctly.
• ✓Recognize common documentation deficiencies found in audits.

Topics covered

• •Accurate and timely documentation
• •Clinical assessment records
• •Medical necessity
• •Treatment planning
• •Progress notes
• •Objective clinical observations
• •Functional impairment
• •Continuity of care
• •Record integrity
• •Documentation deficiencies
• •Common audit concerns

Sources this course is based on

• Medicare exclusions from coverage: reasonable and necessary (42 U.S.C. 1395y(a)(1)(A)) · Other
• Medicare Program Integrity Manual, Chapter 3 (signature requirements; amendments, corrections and delayed entries) (Pub. 100-08, ch. 3, 3.3.2.4 and 3.3.2.5) · CMS
• MLN: Complying with Medical Record Documentation Requirements · CMS
• OIG reports and audits on behavioral health services (search OIG reports for psychotherapy and behavioral health) · OIG