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Basic Billing & Documentation for the Outpatient PMHNP: Answers to Common Questions Asked by New Mental Health Nurse Practitioners & Students
Choosing the right CPT/HCPCS billing code and ensuring that clinical documentation is adequate to support it are complex components of mental health care. Many new and soon-to-be PMHNPs report feeling ill-prepared for the administrative components of understanding, choosing, and reporting billing codes for client encounters.
In this book, I discuss the most common billing codes used by PMHNPs, introduce my seven-step process to grasp the decision-making process of choosing a billing code, and provides examples of documentation.
If you've ever asked
"How can I write more efficiently?
How can I be sure I record enough information?
What if there is a subpoena or audit in the future?
Does my documentation meet coding and billing standards?
Which codes should I choose based on what you charted?"
... then this book is for you.
If you feel like you spend more time documenting your work than performing it and you still wonder if your charting is sufficient for billing purposes, I wrote this book specifically for you to address questions about adequate charting, evaluate content of notes as they relate to billing requirements, break down the SOAP note format into an easy-to-apply format that works for every client interaction, and share time-saving tips.
INTRODUCTION, 6Disclaimer, 9Leveraging Other Resources, 9Billing Codes & Which Comes First?, 11Basics of Coding for Mental Health Care, 15Types of Codes, 16Overview of Billing Codes, 22Categories of Billing Codes, 23Evaluation and Management, 25Psychiatric Diagnostic Evaluation, 31Individual Psychotherapy, 35How to Assign a Billing Code for Each Encounter, 37Tips to Begin Mastering Billing Code Selection in Your Practice, 38Time-Based What counts towards billable time?, 393 Most Common Reasons for Claim Denials, 40Quick-Reference Codes for PMHNPs, 43Decision-Making Algorithm, 50Decision-Making Algorithm Graphic, 52PMHNP Coding Flowsheet Graphic, 57Using a Billing Code to Submit a Claim, 58Overview of Using CMS-1500, 61Section 24 of CMS-1500, 62Meeting Documentation Requirements, 68Overview of Clinical Documentation, 69Establishing Medical Necessity, 71Diagnostic Criteria, 75Functional Impairment, 76Intervention Criteria, 78Common Documentation Questions, 79Common Mistakes in Mental Health Notes, 82Formatting Mental Health Notes, 84How the SOAP format helps PMHNPs graphic, 86SOAP Notes for Mental Health Care, 87Sample Notes for Specific Billing Codes, 99Psychiatric Diagnosis Evaluation, 100 New Client E/M, 104Established Client E/M, 107More Resources, 109References, 111
In this book, I discuss the most common billing codes used by PMHNPs, introduce my seven-step process to grasp the decision-making process of choosing a billing code, and provides examples of documentation.
If you've ever asked
"How can I write more efficiently?
How can I be sure I record enough information?
What if there is a subpoena or audit in the future?
Does my documentation meet coding and billing standards?
Which codes should I choose based on what you charted?"
... then this book is for you.
If you feel like you spend more time documenting your work than performing it and you still wonder if your charting is sufficient for billing purposes, I wrote this book specifically for you to address questions about adequate charting, evaluate content of notes as they relate to billing requirements, break down the SOAP note format into an easy-to-apply format that works for every client interaction, and share time-saving tips.
INTRODUCTION, 6Disclaimer, 9Leveraging Other Resources, 9Billing Codes & Which Comes First?, 11Basics of Coding for Mental Health Care, 15Types of Codes, 16Overview of Billing Codes, 22Categories of Billing Codes, 23Evaluation and Management, 25Psychiatric Diagnostic Evaluation, 31Individual Psychotherapy, 35How to Assign a Billing Code for Each Encounter, 37Tips to Begin Mastering Billing Code Selection in Your Practice, 38Time-Based What counts towards billable time?, 393 Most Common Reasons for Claim Denials, 40Quick-Reference Codes for PMHNPs, 43Decision-Making Algorithm, 50Decision-Making Algorithm Graphic, 52PMHNP Coding Flowsheet Graphic, 57Using a Billing Code to Submit a Claim, 58Overview of Using CMS-1500, 61Section 24 of CMS-1500, 62Meeting Documentation Requirements, 68Overview of Clinical Documentation, 69Establishing Medical Necessity, 71Diagnostic Criteria, 75Functional Impairment, 76Intervention Criteria, 78Common Documentation Questions, 79Common Mistakes in Mental Health Notes, 82Formatting Mental Health Notes, 84How the SOAP format helps PMHNPs graphic, 86SOAP Notes for Mental Health Care, 87Sample Notes for Specific Billing Codes, 99Psychiatric Diagnosis Evaluation, 100 New Client E/M, 104Established Client E/M, 107More Resources, 109References, 111
109 pages, Kindle Edition
Published February 7, 2022
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