Psychotherapy Note Update

As part of its Medlearn Matters, which provides online information for Medicare providers, the Centers for Medicare and Medicaid Services (CMS) issued a Change Request Transmittal clarifying that claims for psychotherapy cannot be denied because of providers' failure to produce psychotherapy notes. The change was implemented February 22.

The issuance of this transmittal is apparently in response to concerns expressed by APA last year about Medicare contractors' demands for psychotherapy notes for claims reviews (see PP&MC, September 17, 2004). The CMS transmittal provides the definition of psychotherapy notes under the Health Insurance Portability and Accountability Act's privacy rule and notes that the definition specifically excludes information about medication prescription and monitoring, session start and stop times, modalities and frequencies of treatment, and results of clinical tests. It also excludes any summary of diagnosis, functional status, treatment plan, symptoms, prognosis, progress, and progress to date, all of which are considered part of the medical record, which is releasable for claims reviews.

There is one new twist conveyed in the transmittal, however: Although psychotherapy notes must be kept separate from the rest of the medical record, if any of the above medical-record information has been combined with psychotherapy-note information, “it is the responsibility of the provider to extract the information needed to support that a Medicare claim is reasonable and necessary.” APA interprets this to mean that you may redact the psychotherapy-note information when submitting medical record information for claims review.