Lessons Learned: The Importance of Clinical Documentation

By Don Wiger, Ph.D., LP

This article is the second in a series of six by Don Wiger. The first article, titled “When You Leave a Clinic: Keep Your Reputation,” appeared in the May-June issue of the Minnesota Psychologist. Parts three through five of this series will explain how to measurably document intakes, treatment plans, progress notes, and outcomes.

What happened? I am proud to have graduated from an excellent graduate school in New York. The first few months of living in New York City, especially as a single parent, were a true cultural shocker for this Minnesota boy. Nevertheless, we adapted and learned much about who we were by living away from home.

In graduate school, I learned from some excellent teachers. To work at this university, instructors had to be quite experienced and well-published--they were clearly experts in their fields. Academically, the program was challenging, but well worth the price paid in time, effort, and personal sacrifice.

When I graduated, I soon took a job as a teacher, counselor, and statistician at a small college in South Carolina. This was great, because I was able to teach, counsel students, and obtain my post-doctoral experience. However, because my training and experience, to date, were typically gratis services for clients, I had few documentation requirements. That is, the treatment plans and progress notes were skeletal, at most.

Of course, this Minnesota boy eventually moved back home. I took a job at a clinic in which I was the only doctoral level psychologist; thus, it was assumed I was quite knowledgeable in most aspects of clinical services. Now, I would be supervising people. However, my training in clinical documentation was minimal.

In the early 1990s, I decided to start my own practice. Having learned about self-employment from my father, I had some knowledge of what it takes to start a business. It is hard work to provide unique services and regularly advertise to potential consumers or referral sources. Within a few years, the practice was running several groups, had a full load of individual clients, and I had found a niche in conducting psychological evaluations.

Because the business grew so quickly, it apparently raised a red flag with Medicaid, and I was contacted to have an audit. When the auditors showed up, they explained the audit was being conducted because the amount of billing had gone from nothing to a fairly high amount in just a few years. The auditors spent a number of days going through records, checking intake notes, treatment plans, progress notes, and appropriateness of services.

A couple months later, the auditors set up a meeting to inform me that I owed several thousand dollars. I was shocked because, to my knowledge, the practice had done nothing wrong. They let me know that, although we followed their guidelines in areas of obtaining a diagnosis, frequency of services, and having a case note for every session, that wasn’t enough.

The auditors, who were not even trained in psychology, provided an education in documentation that was never taught to me in graduate school. They carefully explained the concept of medical necessity, and I learned that my documentation, from the intake, until the termination of services, MUST clearly and measurably document the ongoing need for services. I also learned that you do not have to be a trained psychologist to learn documentation. I learned from the auditors as much as I had gleaned from any professor. Psychotherapy skills, in themselves, are not enough in this age of accountability.

Lesson Learned: Clinical knowledge of psychology or counseling theories is necessary, but not sufficient, in the training of a practicing psychologist. Third party payers have specific guidelines and regulations that determine if the services performed by mental health professionals meet their criteria of medical necessity for services. If there were no such requirements, seeking reimbursement would be similar to paying someone continually to make repairs on something that has never been proven to be broken.

Donald E. Wiger, Ph.D., LP, is a licensed psychologist with a private practice in St. Paul. He has conducted seminars and consultations in documentation since the 1990s. He has written several books on topics such as clinical documentation, practice management, clinical interviewing, and record keeping. Dr. Wiger earned his Ph.D. in 1989 from Fordham University in New York City from the Department of Psychology, specializing in psychometrics. He has an MA (1986) in experimental psychology/psychometrics from Fordham University and an MS (Ed.) (1984) degree in counselor education from the State University of New York.