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What's the difference between progress notes and psychotherapy notes?

(And why it matters when you get a request for records)

As part of our administration of behavioral health benefits and/or claims adjudication on behalf of our customer health plans, it is Magellan's responsibility to implement and regularly conduct fraud, waste, abuse (FWA) and claims overpayment prevention activities that include:

• Monitoring and auditing provider utilization and claims to detect FWA and claims overpayment.
• Investigating and pursuing instances of FWA, claims overpayment, and other alleged illegal, unethical, or unprofessional conduct.
• Reporting suspected FWA, overpayment and related data to our health plan customers and/or federal and state regulatory agencies, in compliance with applicable federal and state regulations and contractual obligations.

Magellan’s Special Investigations Unit (SIU) may choose to conduct a desk audit during an audit or investigation. If you receive a request for treatment records from the SIU, review your records and submit a copy of the full medical record (excluding psychotherapy notes as defined by HIPAA ‑ 45 CFR § 164.501) for each member requested. These records will be used to verify the accuracy of the claims and clinical information you submitted, as well as compliance with applicable provider record keeping requirements. The records that you submit will be used for the purposes of this specific type of review only. Magellan retains records for as long as required by applicable federal and state law and destroys records as required by federal and state law.

What's the difference between progress notes and psychotherapy notes?

Progress notes

Progress notes are a required part of a medical record, and there must be a complete and filed note for each service in the record that supports the medical necessity and reimbursement of the service. These notes encompass a comprehensive overview of a patient's clinical status, including medical history, diagnoses, symptoms, treatment plans, and ongoing progress. They serve as a means of communication among healthcare providers, offering insights into the patient's evolving condition and treatment trajectory.

Psychotherapy notes

Psychotherapy notes should be maintained in a separate file to protect the privacy of those notes and should not be included with the rest of the patient’s medical record. If, however, the psychotherapy notes are integrated into one record, the full record should be submitted.

HIPAA ‑ 45 CFR § 164.501—Psychotherapy notes means notes recorded (in any medium) by a healthcare provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of the individual’s medical record. Psychotherapy notes excludes medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: Diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date. 

Please be assured that Magellan takes patient privacy and confidentiality very seriously, as it is an integral part of our business. As you may know, HIPAA allows providers to disclose protected health information for the healthcare operations of the entity receiving the information as long as we both have (or had) a relationship with the patient, the information pertains to that relationship, and the disclosure of the information is for the purpose of healthcare fraud and abuse detection or compliance. See 45 CFR 164.506(c)(4).

Providers are solely responsible for their own adherence to applicable medical record obligations set forth by state, licensing board, and/or health plan requirements. Providers are expected to maintain appropriate documentation for all claims billed to Magellan to ensure accuracy of records and enable proper reimbursement under the terms of the patient’s health plan.

Lack of compliance with documentation standards may result in:

• An audit/investigation initiated by Magellan SIU.

• Invalidation of payment due to billed services not being supported.
• Any overpayment identified will be referred to Magellan's Cost Containment department for recovery by refund check demand or future claims payment retractions in compliance with applicable contractual and regulatory requirements.
• Magellan completing required reporting to a customer health plan and/or relevant oversight agency.
• Placement of a subset of claims or all claims on a required pre-payment review.
• Termination from the Magellan network.

For more information

• Review Magellan's policy on audits and investigations in Section 4 of Magellan's National Provider Network Handbook (PDF), including:
• Cooperating with Magellan's audits and investigations.
• What to expect during a fraud, waste and abuse (FWA), or overpayment audit or investigation. 

• Contact your Network representative with questions about your contractual obligations to supply medical records for review.

• If you have additional questions regarding our audit/investigation processes, contact the SIU via email (SIU@MagellanHealth.com) or via our hotline 1-800-755-0850 (you may remain anonymous).