Oxford Health Plans (a subsidiary of UnitedHealthcare) recently shocked the psychiatric community by doing a retroactive audit of psychiatric services, and demanding repayment of up to tens of thousands of dollars of reimbursements from some physicians based on insufficient documentation. When clinicians protested, Oxford convened meetings with several professional organizations to agree on documentation standards. They developed a policy that required seven elements for documentation of psychotherapy: (1) Patient name; (2) Clinician name; (3) Date of service; (4) Diagnosis; (5) CPT code or description of service; (6) Other session participants; and, (7) Focus of psychotherapy session. The choices for "Focus of psychotherapy" do not represent content; they are: Assessed family, work, marital, and/or social issues; Assessed symptoms of patient's illness or condition; and Assessed patient's functional status (home, work, daily living, social activities, family, etc.). Providers and payers found this an appropriate resolution, and were pleased with the process; it may serve as a model for the UnitedHealthcare system.

Source: Storman, L; The American Psychoanalyst; May 2005 (http://www.apsa.org/tap/Stormon-Oxford05-05.pdf)