Mastering Accurate Patient Documentation
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Questions and Answers

Which of the following should documentation reflect?

  • Medical or behavioral health changes or challenges not related to level of care billed
  • Interventions not prescribed
  • Patient's objective symptoms
  • Behavioral issues triggering the psychotherapeutic interaction (correct)

    • What is one of the key factors that should be documented in relation to the level of care billed?

  • Interventions not prescribed
  • Patient's objective symptoms
  • Medical or behavioral health changes not related to level of care billed (correct)
  • Patient's subjective symptoms

    • What should documentation include in order to substantiate the level of care billed?

  • Patient's subjective symptoms
  • Behavioral issues triggering the psychotherapeutic interaction
  • Patient's objective symptoms (correct)
  • Interventions not prescribed

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