About this course

Clinical documentation can often create anxiety for therapists: “what needs to be included in case I get audited?” “Is this note too sparse? Too long?”, etc. This three part workshop will provide an overview of what clinicians need to include in their clinical documentation to comply with major insurance company requirements for reimbursement in 2025. Clinicians will learn what to include in their clinical assessment as well as treatment plan. This workshop will instruct clinicians how to format documentation in Therapy Appointment’s software. Clinicians will receive examples of an assessment and treatment plan to use as a reference. Finally, this presentation will explore relevant guidelines, case note options, best clinical practices, and insurance requirements. This presentation aims to enhance basic skills around documentation.

Part 1: Initial Assessment (90791)

Part 2: Treatment Plans

Part 3: Case Notes

Learning Objectives

• Identify the content that needs to be included in the assessment portion of the 90791 note.

• Identify the content that needs to be included in the treatment plan portion of the 90791 note.

• Write a 90791 note that is compliant with insurance requirements using Therapy Appointment templates.

• Demonstrate proficiency in documenting clinical encounters using various case note formats to ensure clear, concise, and organized case notes.

• Analyze and synthesize relevant client data to develop accurate assessments and support clinical decision-making.

• Enhance communication skills by creating structured and professional documentation that facilitates continuity of care and interdisciplinary collaboration.
  

Learning Levels

This is a beginner course.

Target Audience

This workshop was recorded for CCRC Staff. It has been made public for all mental health professionals to use in their own practice location. Please note that some of the discussion and tools are specific to CCRC's EMR Platform, Therapy Appointment, and to our internal documentation process.

Course Instructors

• Sara Morrow, LMFT, PMH-C

  Clinical Director at Chicago Center for Relationship Counseling

  Sara Morrow, LMFT, PMH-C, is the Clinical Director at Chicago Center for Relationship Counseling and the Billing Director at Focht Family Practice. She has been a practicing Marriage and Family Therapist for ten years and is an AAMFT Approved Supervisor as well as Perinatal Mental Health Certified. Through her work as a supervisor and as a biller, she has developed a keen understanding of what content is needed in clinical documentation in order to comply with insurance standards as well as to maintain ethical standards. Learn more about Sara

• Faith Jefferson, MA, QMHP, CADC

  Director of Quality Assurance and Billing & Claims

  I was born and raised in Chicago, Illinois. I hold an associate’s degree in Mental Health and Addiction studies from Kennedy King Community College; one of Chicago’s seven community colleges. I also hold a bachelor’s degree in psychology from Chicago State University, and a Master of Art Degree in Clinical Mental Health from Chicago State University. I am a Certified Alcohol and Drug Counselor in the state of Illinois. I have over 14 years of experience in community mental health and substance abuse.

• Josh Hetherington, LMFT, LCPC

  Family Therapist, President of Chicago Center for Relationship Counseling, P.C., and Board President, Phoenix Clinic NFP.

  I'm trained as a Marriage and Family Therapist. I became a Licensed Marriage and Family Therapist, LMFT, in 2000. I've dedicated my professional life to working with individuals, couples and families on understanding what keeps them stuck and then removing the barriers. This process is collaborative and requires a give and take. I take steps to get feedback from the people I work with to help me understand what is helping, and what is not. I am also dedicated to building the community of helping professionals. I supervise students and professionals and am always excited to meet with other therapists and students to hear about their work and to share my experiences. This community is essential to the longevity of our work. Learn more about Faith

Disclosure

This workshop was recorded for CCRC Staff. It has been made public for all mental health professionals. Please note that some of the discussion is specific to CCRC's EMR Platform, Therapy Appointment, and to our internal documentation process.

References

• Aetna (2023). Treatment Record Review Criteria. pp. Attachment A.

• Blue Cross Blue Shield of Rhode Island (2013). Behavioral Health Medical Record Documentation Standards. pp. 1-5.

• J Flowers Health Staff (n.d.). Setting the Course for Recovery: Defining Goals and Objectives in a Mental Health Treatment Plan. J Flowers Health Institute. Retrieved February 24, 2025, from https://jflowershealth.com/mental-health-treatment-plan-goals-and-objectives/.

• Suls, J. M., Luger, T., & Martin, R. (2010). The biopsychosocial model and the use of theory in health psychology. In J. M. Suls, K. W. Davidson, & R. M. Kaplan (Eds.), Handbook of health psychology and behavioral medicine (pp. 15–27). The Guilford Press.