Avoiding Common Documentation Errors for Behavioral Health Services
The MO HealthNet Division (MHD) wants to help providers of counseling/psychotherapy services avoid common documentation errors identified during provider audits and ensure compliance with record-keeping requirements as outlined in 13 CSR 70-3.030(2)(A). Below are a few common errors providers should watch for:
- Non-Documentation: The most significant issue found during audits is a lack of documentation. Providers must maintain records for all services and be able to produce them upon request.
- Incomplete Family Therapy Records: When documenting family therapy sessions, providers must state both the names and the relationships of everyone present. It is a common error to list the names of attendees without stating their relationship to the participant, or to list the relationships (e.g., “mom” or “dad”) without including their specific names.
- Incorrect Claims Information: Claims must accurately reflect who provided the service. A frequent error occurs when the provider performing the service is not listed on the claim, and only the billing provider is listed.
- Missing Signatures: Performing providers must ensure all documents are signed and dated.
Failure to furnish, reveal, and retain adequate documentation for services billed to MHD may result in recovery of the payments for those services not adequately documented and may result in sanctions to the provider’s participation in the MO HealthNet Program.
Additional information on adequate documentation for behavioral health services is available in the Behavioral Health Provider Manual. Join us on August 4, 2026, at 1:00 pm for a live webinar with a Q and A session for behavioral health providers covering navigating resources, proper billing methods, documentation, and more.
For questions, contact MHD.Education@dss.mo.gov.