Documentation guidelines updated for mental health, substance abuse services

We’ve updated the documentation guidelines for mental health and substance abuse services.
Here are some of the key changes:

• In the section titled “Office or outpatient psychiatric care — general guidelines,” we’ve added a note to the “Initial visit” subsection. The note explains that if this service is provided by a psychiatrist, a medical history must be documented. The medical history must include all prescriptions, over-the-counter medications, and holistic and natural supplements.
• In the “Inpatient and outpatient individual psychotherapy” section, we’ve added a note to the “Progress notes” subsection. The note explains that if a psychiatrist performs psychotherapy and medication management in the same visit, he or she must document the patient’s response to the medication. The documentation should include side effects, as well as a treatment plan related to the medication.
• In the section titled “Inpatient and outpatient group or family therapy,” we’ve added information about inpatient services. We outline what must be documented when a patient from the inpatient unit is able to participate only minimally — or not at all — in psychotherapy.
• In the “Psychological testing services” section, we’ve expanded a bullet point that discusses “the rationale for the referral.” It now mentions that the patient record must contain either a letter from the referring physician or psychologist, or a notation that documents a conversation between the referring physician and the provider of testing services. We’ve also added information on what must be documented if the psychologist is referring the testing to be done by him or her.

For more information, please see the “Documentation Guidelines for Physicians and Other Professional Providers” chapter in your online provider manual. To view the provider manual:

• Go to web-DENIS.
• Click on BCBSM Provider Publications and Resources.
• Click on Provider Manual.