ED Behavioral Health Encounters: Double-Check Documentation Requirements

ED Behavioral Health Encounters

Studies have been showing for a while a glaring problem in the U.S. – inadequate care for patients who show up at emergency departments (EDs) with behavioral health challenges. In the defense of ED staff, these challenges are difficult to assess. Add to that the pressure that if an accurate assessment isn’t made, or if there are gaps in the visit report, payers may not reimburse follow up activities for the patient.

Such issues lead to difficulties both for the patients – whose conditions could worsen without proper care –  and for ED staff and physicians, says auditing and training consultant Dorothy D. Steed in her live webinar with ProfEdOnDemand. During her presentation on behavioral health documentation requirements, Steed discusses the increase of record requests, what the record must contain for proper billing, and how to properly show the medical necessity of patient follow up activities.

Issues Include Overworked ED Staff

Behavioral health concerns present unique challenges to EDs for the following reasons:

  • Often, patients presenting symptoms of issues such as schizophrenia, mood or anxiety disorders, intent to self-harm, or substance abuse also have physical issues such as liver disease, infection, or diabetes. Staff have to be extra sure that treatment for the behavioral health challenges would not worsen the physical issues, or that the benefits outweigh the risks.
  • Despite initiatives to encourage patients presenting behavioral health problems to seek help somewhere besides an ED, many patients have continued to seek out EDs as a first resort because they feel they have nowhere else to go after the closing of several mental health intuitions nationwide.
  • Reports have shown that patients with behavioral health issues often wait longer than patients not presenting behavioral health challenges.
  • Behavioral health issues can be difficult to assess, meaning that staff might not have time to come to a correct assessment (especially with already overcrowded EDs), or the patient may be presenting such complicated symptoms that staff is not able to diagnose correctly the first time around.


Can You Spot the Issue?: Behavioral health challenges are not only high-risk for patients, but also demanding for already stressed-out ED staff, who may not take the time to properly document a behavioral health visit. More payers are asking to see records, meaning that you must always have written evidence of the medical necessity of an activity or service. Without proper documentation, you will not be able to bill properly, which could lead to denied claims and loss of revenue.

7 Elements Required for All Behavioral Health Encounter Reports

To receive reimbursement for behavioral health claims, documentation must, at a minimum, contain the following elements typical of Evaluation & Management (E/M) codes:

  • History
    • Past history of behavioral health challenge(s)
  • Examination
    • Reason for the encounter
    • If patient was endangered or endangering others
    • Assessment/Diagnosis
  • Decision Making
    • Plan of care, along with follow up activities
    • How likely the patient will be to comply with treatment plan
    • How treatment for behavioral health issues will/could affect any medical problems patient is currently experiencing


Be Thorough: As with any type of coding and billing, remember that behavioral documentation requirements and rules often differ from payer to payer. Before submitting your next claim, verify the payer rules and make sure you have everything in place. Taking five minutes to double-check now will save you weeks of hassle, delayed payments and denied claims in the future.

Small Steps Can Pay Big Dividends

Overcrowded EDs are a national problem that might not see a successful resolution any time soon, and patients with behavioral health challenges and few other assistance options will continue to seek help in EDs.

Proper documentation is the simple but not straightforward key to ensuring physicians get paid correctly and on time – and patients get the care they need, says Steed. And by working with ED staff on thorough documentation, you’ll have better records the first go-around for successful billing.

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