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38.4 Documentation Requirements
Services not supported by required documentation in the client's record and medical necessity are subject to recoupment.
Each client for whom services are billed must have the following documentation (which meets the standards indicated) included in their record:
• All entries are clearly documented and legible to individuals other than the author, date (month/day/year), and signed by the performing provider.
•Notations of the beginning and ending session times for counseling and/or each test administered.
•All pertinent information regarding the client's condition to substantiate the need for services, including but not limited to the following:
•Name of test(s) (e.g., Wechsler Adult Intelligence Scale-Revised [WAIS-R], Rorschach, Minnesota Multiphasic Personality Inventory [MMPI]).
•Background and history of client and reason for testing.
•Behavioral observations during the session.
•Narrative description of the counseling session or test findings.
•Diagnosis (symptoms, impressions).
•Treatment plan and recommendations.
•Explanation to substantiate the necessity of retesting, if applicable.
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