Psychotherapy Notes Provision of HIPAA

by  Wyn Staheli, Director of Research
February 2nd, 2017

Of special interest to all behavioral health practitioners (both Covered Entities and NON-covered entities) is HIPAA's provision for psychotherapy notes. The privacy rule recognizes that psychotherapy notes need more protection than other types of PHI. Even if you are not a covered entity, we recommend understanding and implementing office procedures in regards to the psychotherapy notes provision. In order to qualify as psychotherapy notes, “the information must be separated from the rest of the individual's medical record.”

Definition

Psychotherapy notes are defined as “notes recorded (in any medium) by a health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session.” Some professionals refer to these types of notes as 'process notes' or 'personal notes.' The following items are excluded from the HIPAA definition of psychotherapy notes: “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.”

Separate Distinction

It should be noted that there is no HIPAA definition of what is considered “separate.” This is where good clinical judgement determines the action taken. If the clinician feels that the patient’s information does not warrant the extra level of protection, simply having a distinctly separate section in the medical record would mostly likely be sufficient. However, if the information is considered highly sensitive, it would be best to keep those notes in a physically separate record in a different location than your general medical records to avoid any inadvertent disclosures.

Disclosure Rules

Disclosure of psychotherapy notes requires specific “authorization” obtained from the client. According to HIPAA definitions, “authorization” is more than a general “consent.”

Individual authorization is NOT required for the following exemptions:

Note:  Insurance plans cannot refuse reimbursement if the client does not sign an authorization for the release of psychotherapy notes.

 

Psychotherapy Notes Provision of HIPAA. (2017, February 2). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/psychotherapy-notes-provision-of-hipaa-30295.html

© InnoviHealth Systems Inc

Article Tags  (click on a tag to see related articles)


Publish this Article on your Website, Blog or Newsletter

This article is available for publishing on websites, blogs, and newsletters. The article must be published in its entirety - all links must be active. If you would like to publish this article, please contact us and let us know where you will be publishing it. The easiest way to get the text of the article is to highlight and copy. Or use your browser's "View Source" option to capture the HTML formatted code.

If you would like a specific article written on a medical coding and billing topic, please Contact Us.


contact

innoviHealth Systems, Inc.
62 East 300 North
Spanish Fork, UT 84660
Phone: 801-770-4203 (9-5 Mountain)
Email:
free demo
request yours today
pricing
for any budget
sign IN
welcome back!

Thank you for choosing Find-A-Code, please Sign In to remove ads.