CMS-1500 Initiative Medical Narrative Requirements

The subsequent Psychology Narrative should include clinical documentation to support ongoing psychology care and services.

Documentation should include clinical re-evaluation and re-assessment at each treatment session with identification of individual treatment goals, monitoring of progress or lack of progress towards goals and the impact of treatment consistent with must be consistent MTG with MTG General Principles (A.1, A.3, A.4, A.14 and A.15) and recommendations.

• Rendering Provider's Name

Work Status

• Is the patient working? If yes, provide the date(s) the patient:
• Resumed limited work of any kind:
• Resumed full work:

Causal Relationship

• Was the occurrence described above (or in your previous report) the competent producing cause of the injury or disability (if any) sustained?

Assessment

• Current diagnosis(es):
• Results of psychological testing, if applicable
• Assessment of danger to self or others
• Documentation of clinical evaluation and reassessment with identification of individual treatment goals, progress or lack of progress towards specific goals and impact of treatment

Treatment Plan/Recommendations

• For all psychological/psychiatric interventions, there must be documentation of an assessment and treatment plan which include the identification of measurable behavioral goals, specific interventions planned, frequency timeframes, expected outcomes and plan for re-evaluation of treatment
• In the absence of progress towards goals, the psychologist must re-evaluate the diagnosis and treatment plan, with modification of the treatment plan or discontinuation of treatment and/ or referral as clinically indicated.
• When testing is indicated, documentation of the specific indication/rationale for each psychological test performed.
• Tests must be performed and interpreted in correlation with clinical interview data to monitor a patient's condition and progress.
• Diagnosis and treatment must be based on a correlation of the clinical interview data and testing, if indicated.