Behavioral health documentation guidelines now available

When documenting behavioral health services provided to our members, contracted behavioral health providers must follow the guidelines we recently published. The guidelines apply to services for Blue Cross Blue Shield of Michigan PPO (commercial), Blue Cross Medicare Plus Blue^SM, Blue Care Network HMO^SM (commercial) and BCN Advantage^SM members. They were developed for all products to make it easier for providers to locate and follow them.

Where to locate guidelines

You’ll find the guidelines at ereferrals.bcbsm.com. Click on either Blue Cross or BCN, as appropriate. Then click on Behavioral Health.

The guidelines are published in two documents:

• Behavioral health medical record documentation requirements for applied behavior analysis services
• Behavioral health medical record documentation requirements and privacy regulations — for services other than ABA

You can also access the guidelines by visiting bcbsm.com/providers and logging in to Provider Secured Services. Then follow these steps:

• Click on BCBSM Provider Publications and Resources.
• Click on Newsletters and Resources.
• Click on Clinical Criteria & Resources.
• Scroll down to the Behavioral Health Information header.
• Click on the links under the Behavioral Health Medical Record Documentation Requirements subhead.

The guidelines contain the requirements for documenting specific treatments. For applied behavioral analysis, or ABA, this includes line therapy, supervision, parental training or socialization groups, and re-evaluation. For non-ABA treatment, this includes the initial evaluation and subsequent individual, group and family therapy.

Why the guidelines were developed

Over the past few years, Blue Cross and BCN have added new types of providers who have enhanced our networks’ capabilities for care. Some providers have never worked with insurance carriers and haven’t previously had to document their services clearly and specifically enough to match the services billed.

In addition, we’ve had complaints from members that the services billed did not match the services they thought they were receiving. We’ve also been subject to additional reporting requirements from federal and local government agencies and from our accrediting organizations. These require more detailed documentation of services provided.

With these issues in mind, we developed documentation guidelines to align with those published by the Centers for Medicare & Medicaid Services, with local and federal regulatory agencies, with accrediting agencies and with good documentation practices. We feel this will help providers document their care in ways that meet both medical and legal requirements.

Additional information

In each guidelines document, you’ll see requirements for both medical and nonmedical treatment providers. Medical providers (physicians, nurse practitioners and physician assistants) must follow the CMS documentation guidelines in the Medical Learning Network guide ICN 006764 (August 2016).

For nonmedical providers, we’ve outlined detailed documentation requirements for the most common types of interventions that would be used.

When you document these interventions, there’s no need to document anything that did not occur. On the other hand, you should document any interventions you provided in addition to those we listed. That way, you’ll have a way to remember these interventions and these notes will complete the member’s record.

Also, standard care involves using screening tools to document the progress of your patient. Documenting the use of those tools can be helpful in measuring the progress of your patient or in identifying measurably poor progress and the subsequent need to review the treatment interventions provided.

Many electronic medical records already have most of these or all of these items within their database, although it may take some time to learn where they are to make the process go more quickly.

We encourage you to familiarize yourself with the new documentation requirements and start to use them immediately. Over the next few weeks, provider manuals will be updated with hyperlinks to the guideline documents.

Remember: The general rule of thumb is “If it isn’t documented, it didn’t occur.”

None of the information included in this article is intended to be legal advice and, as such, it remains the provider’s responsibility to ensure that all coding and documentation are done in accordance with all applicable state and federal laws and regulations.