Image of Mental Health Documentation & Medical Necessity: Simple, Clear Guideli
Live Webcast

Mental Health Documentation & Medical Necessity: Simple, Clear Guidelines that Maintain Quality of Care and Protect Your Practice


Faculty:
Beth Rontal
Duration:
Full Day
Format:
Audio and Video
Product Code:
LWC055315
Brochure Code:
PLW74765
Media Type:
Live Webcast


Description

“I love paperwork!”.

--Said NO clinician, EVER

Yet, the success of your practice depends on your ability to write good intake summaries, treatment plans, session notes, case/collateral notes, and discharge summaries. Taken together, these pieces to the documentation puzzle support your goal of providing quality services to your clients. They also impact the stability and success of your practice.

When done well, they result in piece of mind and timely payment from insurance companies. When done poorly, they lead to the misery of denials, audits, and lost income. The great news is that you CAN become proficient at mental health documentation and medical necessity.

This live webcast provides clear and simple guidelines for recordkeeping that adheres to professional standards and ethical codes, support delivery of quality care, and reduces errors and delays in payments.

You will receive expert instruction from Beth Rontal, LICSW, affectionally known as the Documentation Wizard. For over 15 years, Beth has been instrumental at changing how individuals and organizations approach documentation. The results speak for themselves.

Rates at which paperwork was returned to clinicians for correction have dropped significantly, in one case from 65% to under 8%. This gave clinicians back 3 to 5 clinical hours per week, saving thousands of dollars and improving job satisfaction.

Credits


*

NOTE: Tuition includes one free CE Certificate (participant will be able to print the certificate of completion after completing and passing the on-line post-test evaluation). 

Continuing Education Information: Listed below are the continuing education credit(s) currently available for this live interactive webcast. This webcast is a broadcast of a live event. You will be able to type questions to the speaker. The speaker will see the questions and address them during the presentation as time allows. Please note, your state licensing board dictates whether web based activities are an acceptable form of continuing education. Please refer to your state rules and regulations. If your profession is not listed, please contact your licensing board to determine your continuing education requirements and check for reciprocal approval. For other credit inquiries not specified below, please contact cepesi@pesi.com or 800-844-8260 before the event.

Materials that are included in this course may include interventions and modalities that are beyond the authorized practice of mental health professionals.  As a licensed professional, you are responsible for reviewing the scope of practice, including activities that are defined in law as beyond the boundaries of practice in accordance with and in compliance with your professions standards.

CE Information is based on 100% attendance.

Information obtained in this course should be used within your scope of practice.


Counselors

This activity consists of 6.25 clock hours of continuing education instruction. Credit requirements and approvals vary per state board regulations. Please save the course outline, the certificate of completion you receive from the activity and contact your state board or organization to determine specific filing requirements.


California Counselors

The California Board of Behavioral Sciences accepts CE programs that are approved by other approval agencies, including several that approve PESI and its programs.  A full list of approval agencies accepted by the BBS can be found at www.bbs.ca.gov/licensees/cont_ed.html under “Where to find CE Courses.”  This level activity consists of 6.25 clock hours of continuing education instruction.


Florida Counselors

PESI, Inc. is an approved provider with the Florida Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling. Provider Number 50-399. This course qualifies for 6.25 continuing education credits.


New York Counselors

PESI, Inc. is recognized by the New York State Education Department's (NYSED) State Board for Mental Health Practitioners as an approved provider of continuing education for Licensed Mental Health Counselors. #MHC-0033. This activity will qualify for 7.5 contact hours. Full attendance is required; no partial credits will be offered for partial attendance


Ohio Counselors

PESI, Inc. is an approved provider with the State of Ohio Counselor, Social Worker and Marriage & Family Therapist Board. Provider approval #:RCST071001. Full attendance at this course meets the qualifications for 6.25 clock hours of continuing education credit. 


Pennsylvania Counselors

The Pennsylvania State Board of Social Workers, Marriage and Family Therapists and Professional Counselors accepts many national association CE approvals, several of which PESI offers. For a full list, please see your State Board regulations at https://www.dos.pa.gov/ProfessionalLicensing/BoardsCommissions/. This activity consists of 6.0 clock hours of continuing education instruction.


South Carolina Counselors

This program has been approved for 6.0 continuing education hours by the South Carolina Board of Examiners for Licensure of Professional Counselors, Marriage and Family Therapists, and Psycho-Educational Specialists. Provider #4540.


Texas Counselors

This activity consists of 6.0 clock hours of continuing education instruction. Texas State Board of Examiners of Professional Counselors no longer approves programs or providers. PESI activities meet the continuing education requirements as listed in Title 22 Texas Administrative Code, Chapter 681, Subchapter J, Section 681.142 Acceptable Continuing Education. Please retain the certificate of completion that you receive and use as proof of completion when required.


Marriage & Family Therapists

This activity consists of 380 minutes of continuing education instruction. Credit requirements and approvals vary per state board regulations. Please save the activity advertisement, the certificate of completion you receive from the activity and contact your state board or organization to determine specific filing requirements. 


Florida Marriage & Family Therapists

PESI, Inc. is an approved provider with the Florida Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling. Provider Number 50-399. This course qualifies for 6.25 continuing education credits.


Illinois Marriage & Family Therapists

PESI has been approved as a provider of continuing education by the State of Illinois, Department of Professional Regulation. Provider #:168-000156. Full attendance at this activity qualifies for 6.0 credits. 


New York Marriage & Family Therapists

PESI, Inc. is recognized by the New York State Education Department's (NYSED) State Board for Mental Health Practitioners as an approved provider of continuing education for Licensed Marriage and Family Therapists. #MFT-0024. This activity will qualify for 7.5 contact hours. Full attendance is required; no partial credits will be offered for partial attendance


Ohio Marriage & Family Therapists

PESI, Inc. is an approved provider with the State of Ohio Counselor, Social Worker and Marriage & Family Therapist Board. Provider approval #:RCST071001. Full attendance at this course meets the qualifications for 6.25 clock hours of continuing education credit. 


South Carolina Marriage & Family Therapists

This program has been approved for 6.0 continuing education hours by the South Carolina Board of Examiners for Licensure of Professional Counselors, Marriage and Family Therapists, and Psycho-Educational Specialists. Provider #4540.


Texas Marriage & Family Therapists

This activity consists of 6.0 clock hours of continuing education instruction. Texas State Board of Examiners of Marriage and Family Therapists no longer approves programs or providers. PESI activities meet the continuing education requirements as listed in Title 22 of the Texas Administrative Code, Chapter 801, Subchapter K, Section 801.264 Types of Acceptable Continuing Education. Please retain the certificate of completion that you receive and use as proof of completion when required.


Nurses, Nurse Practitioners, and Clinical Nurse Specialists

PESI, Inc. is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

Nurses in full attendance will earn 6.3 contact hours.


California Nurses

PESI, Inc. is a provider approved by the California Board of Registered Nursing, Provider Number 17118 for 6.0 contact hours. Full attendance is required. No partial contact hours will be issued for partial attendance. 


Florida Nurses

CE Broker

PESI, Inc. is an approved provider with the Florida Board of Nursing, Provider # FBN2858. This course qualifies for 6.0 contact hours. 


Iowa Nurses

PESI, Inc. is an approved provider by the Iowa Board of Nursing. Provider #: 346. Full attendance at this activity qualifies for 6.3 contact hours. Full attendance in the activity is required; no partial contact hours will be issued for partial attendance. These contact hours are used for your license renewal. Please email cepesi@pesi.com with your license number, include the webcast title, speaker name and date. PESI must have this number on file in order for your hours to be valid for the webcast.


California Psychologists

PESI, Inc. is approved by the California Psychological Association to provide continuing education for psychologists. Provider #PES010. PESI maintains responsibility for this program and its contents. PESI is offering this activity for 6.25 hours of continuing education credit. Full attendance is required; no partial credits will be offered for partial attendance.


Canadian Psychologists

PESI, Inc. is approved by the Canadian Psychological Association to offer continuing education for psychologists. PESI, Inc. maintains responsibility for the program. This program is approved for 6.0 continuing education hours. Full credit statement at: www.pesi.com/cpa-statement


Florida Psychologists

PESI, Inc. is an approved provider with the Florida Board of Psychology. Provider Number #50-399. This course qualifies for 6.3 continuing education credits.


Illinois Psychologists PESI, Inc is an approved provider with the State of Illinois, Department of Professional Regulation. License #: 268.000102. Full attendance at this course qualifies for 6.0 contact hours.
Illinois Psychologists

PESI, Inc is an approved provider with the State of Illinois, Department of Professional Regulation. License #: 268.000102. Full attendance at this self-study course qualifies for 6.25 contact hours.


Indiana Psychologists

PESI, Inc is an approved provider with the Indiana Board of Psychology. Certificate #: 98000998A - Category I. PESI maintains full responsibility for this program and its contents. Full attendance at this course qualifies for 6.25 contact hours.


Kentucky Psychologists

PESI, Inc. is approved by the Kentucky Board of Examiners of Psychology to offer continuing education for psychologists. PESI maintains responsibility for this program and its content. This activity will qualify for 6.25 contact hours.


New York Psychologists

This live activity consists of 380 minutes of continuing education instruction and is related to the practice of psychology. 


Ohio Psychologists

PESI, Inc. is approved by the Ohio Psychological Association, Provider #263896894, to sponsor continuing education for psychologists. PESI, Inc. maintains responsibility for this program and its content. PESI is offering this activity for 6.25  hours of continuing education credit. 


Pennsylvania Psychologists

PESI, Inc. is approved by the Pennsylvania State Board of Psychology to offer continuing education for psychologists. Provider #PSY000211. PESI maintains responsibility for the program(s). This program qualifies for 6.25 continuing education hours.


Psychologists & Psychiatrists

Psychiatrists: PESI, Inc. is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. PESI, Inc. designates this enduring material for a maximum of 6.0 AMA PRA Category 1 Credit(s). Psychiatrists should only claim credit commensurate with the extent of their participation in the activity.

 

Psychologists: The following state psychologist boards recognize activities sponsored by PESI, Inc. as an approved ACCME provider: Alaska, Arkansas, California, Colorado, Georgia, Illinois, Indiana, Kentucky, Maine, Maryland, Missouri, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, Oklahoma, Pennsylvania, South Carolina and Wisconsin. This activity consists of 6.0 clock hours of continuing education instruction. You are required to successfully complete and submit a post-test prior to receiving a certificate of completion. Certificates of attendance will be issued for you to submit to your state licensing board to recognize for continuing education credit. Full attendance is required; no partial credits will be offered for partial attendance.


Social Workers

PESI, Inc., #1062, is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved as ACE providers. State and provincial regulatory boards have the final authority to determine whether an individual course may be accepted for continuing education credit. PESI, Inc. maintains responsibility for this course. ACE provider approval period: January 27, 2017 - January 27, 2020. Social Workers completing this course receive 6.25 Clinical Practice continuing education credits. Course Level: Intermediate. Full attendance is required; no partial credits will be offered for partial attendance. A certificate of attendance will be awarded at the end of the program to social workers who complete the program evaluation.

 

Canadian Social Workers: Canadian provinces may accept activities approved by the ASWB for ongoing professional development.


Colorado Social Workers

PESI, Inc. is an approved provider with the Colorado Chapter of the National Association of Social Workers. Provider #1413. This course has been approved for 6.3 continuing education hours. 

 

COLORADO PARTICIPANTS ONLY: To be reported to the Colorado Chapter of the NASW, after completing and passing the online post-test/evaluation, please contact cepesi@pesi.com and provide the full title of the webcast, speaker name, date of live broadcast, your name and your license number in the email.


Florida Social Workers

PESI, Inc. is an approved provider with the Florida Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling. Provider Number 50-399. This course qualifies for 6.25 continuing education credits.


Illinois Social Workers

PESI, Inc is an approved provider with the State of Illinois, Department of Professional Regulation. License #: 159-000154. Full attendance at this course qualifies for 6.0 contact hours.


Kansas Social Workers

PESI, Inc. is an approved provider with the Kansas Behavioral Sciences Regulatory Board. Provider #14-006. This course has been approved for 6.0 continuing education hours.


Minnesota Social Workers

PESI, Inc. is an approved provider with the State of Minnesota, Board of Social Work. Provider #: CEP-140. This course has been approved for 6.0 continuing education hours. This certificate has been issued upon successful completion of a post-test.


New Jersey Social Workers

Mental Health Documentation & Medical Necessity: Simple, Clear Guidelines that Maintain Quality of Care and Protect Your Practice, Course #2704, is approved by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program to be offered by PESI, Inc. as an individual course. Individual courses, not providers, are approved at the course level. State and provincial regulatory boards have the final authority to determine whether an individual course may be accepted for continuing education credit. ACE course approval period: 10/29/2019 - 10/29/2021. Social Workers completing this course receive 6.25 Clinical Practice and continuing education credits. No more than 6.25 total CE hours may be awarded for this activity. Full attendance is required; no partial credits will be offered for partial attendance.


New York Social Workers

PESI, Inc. is recognized by the New York State Education Department's (NYSED) State Board for Social Work as an approved provider of continuing education for licensed social workers #SW-0008. This activity will qualify for 7.5 contact hours. Full attendance is required; no partial credits will be offered for partial attendance. 


Ohio Social Workers

PESI, Inc. is an approved provider with the State of Ohio Counselor, Social Worker and Marriage & Family Therapist Board. Provider approval #:RCST071001. Full attendance at this course meets the qualifications for 6.25 clock hours of continuing education credit. 


Other Professions

This activity qualifies for 380 continuing education minutes as required by many national, state and local licensing boards and professional organizations. Save your activity advertisement and certificate of completion, and contact your own board or organization for specific requirements. 



Handouts

Faculty

Beth Rontal Related seminars and products: 3

LICSW


Beth Rontal, LCSW, is a psychotherapist in private practice in Brookline, Massachusetts, as well as a documentation consultant (wizard) and private supervisor. Ms. Rontal earned her MFA from Boston University, and her Master’s in Social Work from Simmons College in Boston.

She was clinical supervisor at a mental health clinic for 16 years, where she was instrumental in developing and implementing the clinic’s first electronic documentation system. This implementation significantly reduced documentation time and errors and decreased the paperwork returned by clinicians from 65% to 8%, which in turn allowed for the addition of 3 to 5 clinical hours per week and generated thousands of dollars in savings for the company. 

Ms. Rontal continues to be a developer and consultant in the field of clinical documentation. She is a sought-after national lecturer who has taught seminars over the course of many years, in addition to having published numerous articles on the topic. 

Speaker Disclosures:

Financial: Beth Rontal is in private practice. She has intellectual property rights to Documentation Wizard. Ms. Rontal receives a speaking honorarium from PESI, Inc. 

Non-financial: Beth Rontal has no relevant non-financial relationship to disclose.


Additional Info

Program Information

CD/DVD

Click here to purchase the DVD or CD recording from our product store. CE hours and approvals on products may differ from live CE approvals.


Additional Resources

To order the book, Diagnosis Made Easier, 2nd Edition, please visit our product store.

To order the book, Private Practice Essentials, please visit our product store.


Access Period for Live Webcast

For live CE credit, you must watch the live webcast in its entirety at its scheduled time and complete the CE quiz and evaluation within one week. You will have access for 90 days after the program for review.


Webcast Schedule

Please note: There will be a lunch and two 15-minute breaks; one in the morning and one in the afternoon. Lunch and break times will be announced by the speaker and at their discretion. A more detailed schedule is available upon request.


Objectives

  1. Explain the importance of proper documentation in informing clinical decision-making.
  2. Evaluate the role of the clinical diagnosis in justifying medical necessity and providing more effective services to clients.
  3. Determine how to use the behavioral language required by insurance companies to facilitate delivery of services to clients.
  4. Explain how to document what really happens in a clinical session without violating privacy or confidentiality.
  5. Assess medical necessity by employing the “golden thread” for improved treatment outcomes.
  6. Identify potential red flags in documentation and the proper corrective measures for them

Outline

Get Past Your Negative Feelings About Documentation
  • Documentation as a contributor to good clinical work
  • Documentation through the lens of the “Golden Thread”
  • Documentation as a protector of income and integrity
  • Anxiety-reducing answers to common questions
Embrace the Requirement of Medical Necessity
  • The elements of medical necessity
  • The “Golden Thread” as a key part of medical necessity
  • Establish the connection between diagnosis and treatment
How to Write:
  • The Diagnostic Summary
    • What’s needed in the diagnostic summary, and why
    • How the diagnostic summary initiates the path of the Golden Thread
  • The Treatment Plan
    • What’s needed in a treatment plan, and why
    • Operationalize the presenting problem
      • Questions to ask
      • Describe the diagnostic criteria in behavioral terms
    • Make a clear connection between goals, objectives, and interventions
    • Protect the client and the therapist with a thoughtful risk assessment
    • Evaluate client progress
    • How the treatment plan it continues the path of the Golden Thread
    • And more …
    • Activity: Write a treatment plan
  • The Session Note
    • The session’s note relationship to the treatment plan
    • What’s needed in a session note and why
    • Descriptive or narrative approach to interventions used
    • Changes to treatment plan
    • Justify multiple sessions
    • Activity: Write a session note
  • The Case and Collateral Contact Note
    • What’s needed in a case and collateral contact note and why
    • Differences between case and collateral contact notes
    • Provide a clinical justification for the case/collateral consult
  • The Discharge Summary
    • What’s needed in a discharge summary, and why
    • How the discharge summary completes the Golden Thread
20 DOCUMENTATION RED FLAGS THAT LEAD TO TROUBLE

Target Audience

  • Mental Health Administrators
  • Marriage and Family Therapists
  • Psychiatrists
  • Psychologists
  • Counselors
  • Social Workers
  • Office Managers
  • Mental Health Nurses
  • Other Mental Health Professionals

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