Esther Perel’s definition of self-esteem is, “Seeing yourself as a flawed person, and still holding yourself in high regard.”

It’s a common occurrence that clients come to treatment feeling broken and hopeless, reporting low self-esteem, and not believing they will ever be able to hold themselves in “high regard.”

One of the criteria for Dysthymia is “low self-esteem”.  So “improving self-esteem” seems like a reasonable therapeutic goal, right?

But insurance companies do not authorize or pay for sessions to “improve self-esteem” because it is not descriptive enough. 

Insurance companies want to know you are treating a person, not a diagnosis. One person’s low self-esteem looks different than another’s and measuring self-esteem is impossible without describing behavior. So it makes sense to find out the behaviors that demonstrate low self-esteem specific to the client. It also helps the client and the therapist identify when things are changing — because change shows up in behavior. So,

DO NOT…

• include, “poor self-esteem” as a description of a clinical problem or
• use ‘improve self-esteem” as a goal on a Treatment Plan or Session Note.

INSTEAD…

1. Describe how the low self-esteem looks in the Presenting Problem. You might ask your client, “What does low self-esteem make you do or not do?”
2. Then, when describing the Problem, document that behavior.
3. In the Goal, document what will happen to the behavior when the client’s self-esteem has improved.

For example, when I supervised clinicians at an agency for 11 years, one supervisee told me that several of her clients had low self-esteem. When I asked her what that looked like, she reported that one client, “slept with a lot of guys”.  Another client couldn’t couldn’t finish a work assignment on time.  These two very different presentations of low self-esteem need to documented as such.

An insurance company may not pay for low self-esteem but they will pay to reduce or eliminate engagement in risky behavior and improve work performance!  Plus, you and the client have now identified key behaviors that indicate when self-esteem is improving. When the goal is reached, the client, like the rest of us, is still flawed — but also still able to hold themselves in high regard. (Goal Achieve!)

Thank you, Esther Perel for a great definition of self-esteem.  To prevent a recoupment or claw back from an insurance audit — and to support the client in knowing when life is getting better, describe specifically the negative behavior that will change when self-esteem improves.

 

A therapist recently asked me how to handle a request from the Social Security Administration for the medical records of a client she hadn’t seen in several months and only for two sessions.  The request was accompanied by a signed release so it was legitimate.

Not having access to the client’s medical record could be problematic if this therapist is audited.  But the real issue at this moment is whether this therapist is truly qualified to comment on this client’s ability or inability to work having seen her only two times and not recently.

When my supervisees face this situation I tell them that the client needs to be seen at least six times before an assessment can be made so that professional integrity is maintained. This stand can sound harsh to people who need aid and have no other place to turn.  But the recommendation is not about refusing to write the letter or complete the form.  It’s about having no useful information. The SSI and SSDI forms are extensive requiring specific answers that in my experience, are not provided in the first two sessions. It can take me up to two sessions just to complete a form properly let alone do an Intake Session. The good news is that the discussion about the client’s level of ability to perform tasks of daily living can provide a lot of good information for the therapeutic process itself.

Many couples presenting for couple’s therapy do not fit into a billable diagnostic category. How do I write a treatment plan and session notes — or bill the insurance company if I don’t have a diagnosis?

I’ve been getting a version of this question in my workshops, Misery or Mastery; Documenting Medical Necessity ever since I started leading them four years ago.

Couples don’t seek out therapy because they have a diagnosable mental health issue. They come to therapy because they’re having marital problems they want to solve. What they don’t know is that in order to use their insurance, they need a mental health diagnosis. When it comes to billing an insurance company, diagnosing for couple’s counseling poses unique problems.

• If “the couple is the client”, which person do I use to bill the insurance company?
• What if there is no diagnosis?

Even though “the couple is the client”, in order to bill an insurance company, it’s necessary to have an identified client who has a mental health diagnosis. Once you meet the couple, you sometimes discover that indeed, at least one does meet criteria that supports an ICD 10 diagnosis. Bill the insurance company under that person.

If there is clearly no mental health issue, the answer is simple. You explain the good news to the couple; that they aren’t sick because they don’t meet criteria for a mental health disorder. Then you explain the bad news; that you can’t ethically bill their insurance company for the same reason. Though the answer is straight forward, it clearly poses a problem for those couples who can’t afford to pay out of pocket or expected to use their insurance, which is nearly everyone. And clinicians suffer the loss of income.
If you suspect there might be a mental health problem but aren’t yet sure or you need time to find out, there’s another option. Consider using Adjustment Disorder Unspecified and indicate that the adjustment is in regards to the issues in the marriage.

When completing the Universal Authorization, make sure to write a short narrative in the space provided on the form that explains the issues being address and how they impair the marriage. Use behavioral language that gives clear examples of the problems and their severity. For example, “Couple engages in verbal fights multiple times per week.” Make sure to include any bio-psycho-social stressors that may impact treatment. Here are two examples:

• Their children find these fights very distressing and cause them to act out both at home and school, which causes further conflict between the parents.
• Client is on the verge of losing his or her job, which is contributing to conflicts between couple.
• Client’s wife is the primary care taker of an aging parent who needs constant attention, causing wife to have increased irritability and greater friction between couple.

When a couple seeks help, there are often multiple stressors in their lives so finding some should not be difficult. Many of these stressors can be coded and found in the DSM 5 under T and Z Codes.  Do not use T and Z Codes as a primary diagnosis because they aren’t medical in nature and therefore not reimbursable. But they do support continued treatment and are important to document in the authorization.

There is a caveat to using the Adjustment Disorder strategy.  An Adjustment Disorder has a six-month time limit so using it for more than six months may be a red flag for insurance companies, which could trigger a denial or telephonic review. Unspecified Disorders can also trigger a rejection or review because they do not meet criteria for any specific medical problem. BUT – they are a good starting point and will buy you at least six months’ worth of time to gather information, make a diagnostic decision and help the couple at the same time. Lots of good work can be done in six months and by that time you may have discovered a way to continue justifying medical necessity and get the sessions needed to continue helping your couple.