What are the documents Psychiatry Services needed

Documentation needed for Psychiatry Services

•    Please be sure documentation submitted is legible.
•    Please submit records for all dates of service on the claim.
•    Please ensure the medical records submitted provide proof the service(s) was ordered and rendered. Also, ensure the medical records provide justification supporting medical necessity for the service by submission of the following documentation:
o    Physician’s progress notes.
o    Physician orders.
o    Procedure notes.
o    Physician supervision and evaluation.
o    History and physical.
o    Individualized treatment plan for psychiatric services.
o    Daily individual and group therapy notes.
o    Nurse’s notes.
o    Medication records.
o    Initial psychiatric/psychological evaluation/mental status exam.
o    Medical and psychiatric history.
o    Any diagnostic tests and results.
o    Any re-evaluations.
o    All progress notes/summaries.
o    Plan of treatment.
o    Any adjustments or revisions to the plan of treatment.
o    Treatment plan reviews.
o    Patient goals and progress toward goals.
o    Evidence of attempts to decrease frequency of visits and results of those attempts if treatment is ongoing.
o    Signatures/credentials of professionals providing services.
o    Documentation to support type of or timed codes billed.
o    Any other documentation a provider deems necessary to support medical necessity of services billed, as well as documentation specifically requested in the Additional Documentation Request (ADR) letter.