By ANN BIERMAN
With many changes occurring during the COVID-19 pandemic, MedUSA has two recommendations that should be reviewed and implemented in order to conform with HIPAA guidelines.
First and foremost, with regards to the separation “safe keeping” of Progress and Psychotherapy notes:
- It is important to maintain Progress notes and Psychotherapy notes (also referred to as “process notes”) in separate folders and separate locations in your medical records system.
There has been an increase in the number of requests we are receiving for progress notes by Payers. While most of these are reasonable requests, primarily in support of higher levels of coding, others fall into a gray area, especially in the case of behavioral health providers.
How do you comply with the requirement to be reimbursed while maintaining HIPAA compliance and being sensitive to patient privacy?
HIPAA’s psychotherapy notes provision signed in 2003 safeguards sensitive patient information. However, it is critical that you, the provider as well as your staff, follow certain guidelines pertaining to the handling of these documents as well as the proper storage of all documents during a consultation or session. If all documents are stored in the same location, the office staff may confuse the terms Progress notes and Process notes and share private information that should not be shared according to HIPAA’s guidelines.
A patient’s file whether hard copy or electronic, should include basic demographic and insurance billing information along with the primary reason the patient is seeking treatment. The patient’s past history and family history can also be stored in the patients file documenting diagnoses used by other providers or a list of symptoms the patient or a family member has been treated for or experienced.
It is also important to have the patient sign consent to release or more importantly, not to release their sensitive information discussed during a session. According to the provision signed February 2003, HIPAA requires more than just a generalized consent to share their information. It requires patient authorization to release any or all sensitive information to ANY 3rd party.
Before this provision, the patient could refuse to share their information but the insurance could also refuse to cover services. The HIPAA privacy rule implemented now protects the patient from the insurance company refusing to pay for a covered service within their policy regardless of whether session notes are shared.
Insurance Companies and Attorney requests “for notes” must be handled with care in providing ONLY Progress notes that consist of a diagnosis, plan of care, and patient progress. These are the only “notes” that should be stored within the patients file.
Any notes or recordings of any kind during a private session should be securely stored and always separate from the patients file. Session notes are the opinions of the provider to assist in a diagnostic opinion and could contain personal names or places of events recalled by the patient. A session note or recording of the session are considered Psychotherapy notes and are always kept private. These notes are never shared with any third party requests. Even court summons are not entitled to Psychotherapy notes unless there is a hard reason to believe there is documented harm executed to another person or prior plans to harm another individual or group of individuals.
Most States have laws in place that are even tighter when it comes to protecting patient privacy. HIPAA requires specific patient permission “signed consent” for the release of any personal information discussed during any encounter (Psychotherapy Notes) and more importantly – Insurance Companies cannot deny payment if the patient has not given permission to share their private information.
Please be sure any staff member, office clerk, or any other provider only has access to the patients file and the Progress notes for the patient. This will assure when notes are requested by any 3rd party, the proper set of notes Progress Notes are the only notes provided.
Ann Bierman is a certified Medical Biller and Coder who has been employed as a Senior Medical Billing specialist at MedUSA since 2001. For additional information contact Suresh Thekkenmar 800-244-6550 or firstname.lastname@example.org