Behavioural Health Concerns In A Medical Encounter: What Should You Report?

Dorothy Steed

Dorothy Steed

Dorothy Steed (MSLD, CCS, CDIP, COC, CPCO, CPUM, CPUR, CPHM, CPMA, ACSOP, CCS-P, RCC, RMC, CEMC, CPC-I, CFPC, PCS, FCS, CRCR, CICA, CPAR) is an Independent Healthcare Consultant and Educator in Atlanta. She was a Medicare specialist for a large hospital system and a physician audit supervisor for another hospital system, with 44 years of...
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60 Mins
Dorothy Steed

Many medical providers have seen an increase in behavioural health concerns when patients present for a medical-related encounter. The pandemic has contributed to those increases and either directly influence management problems or appear in varying Social Determinants of Health that have bearing on medical management and outcomes.  

In the past, medical providers may not have needed to address behavioural health influences, whereas now, there may be real concerns to be managed either by personal care plan changes or by engaging a behavioural health specialist to assist in the patient’s management.  

Increased factors have been the use of alcohol or other substance abuse, domestic abuse, loss of income, unstable living arrangements and others. With these added pressures, patients may become non-compliant with necessary health management.  

When increased or new behavioural health concerns are identified, they should be documented in the medical record including recommended care plan and any patient noncompliance. Barriers to meet the recommendations should be included in the documentation. Your coding should reflect the presenting problems including the behavioural health issues.   

This webinar by expert speaker Dorothy Steed will review common scenarios and how the provider should incorporate conditions into the medical record. Many providers have experienced an increase in claims denials related to medical necessity situations. Your documentation and coding accuracy will support your claim if challenged by a payor and increase your chances for denial appeals to be overturned. 

Webinar Objectives

  • Review of behavioral health concerns identified in a medical-related encounter with appropriate documentation of all conditions managed or contributing to the patient’s problems.
  • Complete coding to reflect both medical and behavioral health management.
  • Problems that relate to the pandemic should be connected in the documentation.
  • Ensure that the medical necessity is clearly indicated in your record.  

Webinar Highlights

  • Examples of encounters include both medical and behavioral health concerns.
  • What should be reported in your coding?
  • Identify potential barriers that may contribute to patient noncompliance!
  • Identify prior treatments including behavioral health management.
  • Were they effective?  Short term?  Long term?
  • Social Determinants that are interfering with progress?

Who Should Attend

  • Medical coders
  • Billers
  • Physicians
  • Mid-level providers
  • Clinical documentation specialists
  • Compliance staff
  • Revenue cycle staff
To access this webinar, kindly reach out to our customer support team at

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