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# Is Your Documentation Honestly Reflecting Your Therapy Sessions?

Susan Day
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May 31, 2017

## Is Your Documentation Honestly Reflecting Your Therapy Sessions?

Many patients will come into your practice and tell you they have a problem in a particular area. However, as an expert in your field you will know that there are more than likely other issues underlining this problem, which need to be addressed too.

So, how do you make sure your documentation accurately covers the primary diagnosis you are treating?

Is Your Documentation Honestly Reflecting Your Therapy Sessions

## Documenting the Primary Diagnosis

Let’s look at an example:

A couple come to see you for marital therapy. For any therapist, it is rewarding seeing a couple work through difficult problems and find success in a relationship they thought would never last.

But, what if their insurance company doesn’t cover marital therapy?

You are going to have to tell them up front that they are responsible for paying for the sessions if you don’t want to run into problems with their insurance company.

If you can identify that one of your clients has a specific diagnosis which is exacerbated by the marital problem, however, then this is a different matter.

If you are convinced that the primary diagnosis being addressed and therefore treated in your sessions is covered then it is okay to state that you are treating it in your documentation.

Try to be as upfront as possible with your documentation

## Being Upfront and Honest

It is not okay to provide marital therapy and call it something else or apply a diagnosis simply so that you can get the sessions paid for by the clients’ insurance company.

This might be a choice some therapists consider because they’d rather not tell the client that they’re going to be financially responsible for the services they seek.

This is understandable because you wouldn’t want the couple declining the help they need because they can’t afford it.

However, it is not okay if your documentation is inconsistent with your diagnosis. You certainly don’t want to run into problems with an insurance company.

Always ensure you are recording the right diagnosis and you will avoid getting yourself into hot water.

Make sure all your documentation is clear -