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This is what I got from my local Medicare carrier (Empire). I would check with your carrier as well.

Documentation Requirements

· The medical record must be prepared within a reasonable time period after the rendering of professional services consistent with accepted practice.

· The Health Insurance Portability and Accountability Act of 1996 (HIPAA) has imposed specific restrictions on access to psychotherapy notes. These restrictions are outlined in the Code of Federal Regulations (CFR), 45 CFR, parts 160 and 164 (The Privacy Rule). Providers are exempt from submitting psychotherapy notes without patient authorization when the notes in question fit the Privacy Rule definition in 45 CFR section 164.501. This section defines psychotherapy notes as “notes recorded by a mental health professional (in any medium) which document or analyze the contents of a counseling session and that are separated from the rest of a medical record.”

· 45 CFR § 164.501 states that “the provider is responsible for extracting information required to perform a review for medical necessity.” The provider, therefore, is expected to document information potentially necessary for review in a manner that will allow submission if this information without release of psychotherapy details that are protected by the Privacy Act.

· This definition excludes the following items which must be contained or readily inferred from the medical record, and must be available upon request:

- Name of beneficiary and date of service
- Type of service (Individual, group, family, interactive, etc.)
- Time element (duration), (where time is an element of the face-to-face contact for the service rendered)
- Modalities and frequencies of treatment furnished
- A clinical note for each therapy session that summarizes the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date. Elements such as treatment plans, functional status and progress/prognosis assessment are expected to be documented, updated and available for review, but do not need to be delineated for each individual date of service.
- Identity of person performing service

· For interactive therapy, medical record should indicate the adaptations utilized in the session and the rationale for employing these interactive techniques

· For services that include a medical evaluation and management component, documentation of the medical evaluation or management component of the treatment, including prescriptions, monitoring of medication effects and results of clinical tests.

Hope it helps.

April