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 yourself:

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.

Inside:

INTRODUCTION, 6 Disclaimer, 9 Leveraging Other Resources, 9 Billing Codes & Documentation: Which Comes First? , 11 Basics of Coding for Mental Health Care, 15 Types of Codes, 16 Overview of Billing Codes, 22 Categories of Billing Codes, 23 Evaluation and Management, 25 Psychiatric Diagnostic Evaluation, 31 Individual Psychotherapy, 35 How to Assign a Billing Code for Each Encounter, 37 Tips to Begin Mastering Billing Code Selection in Your Practice, 38 Time-Based Codes: What counts towards billable time? , 39 3 Most Common Reasons for Claim Denials, 40 Quick-Reference Codes for PMHNPs, 43 Decision-Making Algorithm, 50 Decision-Making Algorithm Graphic , 52 PMHNP Coding Flowsheet Graphic , 57 Using a Billing Code to Submit a Claim, 58 Overview of Using CMS-1500, 61 Section 24 of CMS-1500, 62 Meeting Documentation Requirements, 68 Overview of Clinical Documentation, 69 Establishing Medical Necessity, 71 Diagnostic Criteria, 75 Functional Impairment, 76 Intervention Criteria, 78 Common Documentation Questions, 79 Common Mistakes in Mental Health Notes, 82 Formatting Mental Health Notes, 84 How the SOAP format helps PMHNPs graphic , 86 SOAP Notes for Mental Health Care, 87 Sample Notes for Specific Billing Codes, 99 Psychiatric Diagnosis Evaluation, 100 New Client E/M, 104 Established Client E/M, 107 More Resources, 109 References, 111