Key Takeaways
- Private practice requires an LCSW license, malpractice insurance, a business plan, and compliance with state regulations
- Managed care organizations (MCOs) require prior authorization, utilization review, and adherence to medical necessity criteria
- CPT codes are used for billing psychotherapy services, with different codes for different session lengths and modalities
- Telehealth practice has expanded significantly and requires compliance with state licensing laws, HIPAA, and informed consent specific to remote services
- Clinical documentation must include progress notes, treatment plans, and session summaries that meet insurance and legal standards
- The SOAP note format (Subjective, Objective, Assessment, Plan) is widely used for clinical documentation
- HIPAA compliance in clinical settings requires safeguarding all forms of protected health information
Clinical Mental Health Practice
Clinical social work in mental health settings encompasses private practice, community mental health centers, and integrated healthcare systems. Social workers at the clinical level (LCSW) are increasingly providing psychotherapy, managing caseloads, navigating insurance systems, and using technology to deliver services. The ASWB exam tests your understanding of the practical and regulatory aspects of clinical practice.
Private Practice Considerations
Establishing a private practice requires careful planning and compliance with multiple regulatory requirements:
Prerequisites for Private Practice:
- LCSW licensure (or equivalent) in the state where you will practice
- Professional liability (malpractice) insurance — essential for protection against claims
- Business structure: Sole proprietorship, LLC, or professional corporation
- Credentialing: Enrolling as a provider with insurance panels (Medicare, Medicaid, commercial insurers)
- HIPAA compliance: Secure electronic records, privacy policies, Business Associate Agreements
- Informed consent documents: Tailored to private practice setting
- Emergency protocols: Procedures for after-hours crises, including backup coverage
Challenges of Private Practice:
- Inconsistent income, especially when starting out
- Administrative burden (billing, insurance, scheduling, marketing)
- Professional isolation without colleagues or built-in supervision
- Managing high-risk clients without institutional support
- Maintaining continuing education and professional development independently
Managed Care and Insurance
Managed Care Organizations (MCOs) control healthcare costs by requiring prior authorization, utilization review, and adherence to medical necessity criteria.
| Managed Care Concept | Description |
|---|---|
| Prior Authorization | Approval required before treatment begins or at specific intervals |
| Utilization Review | Review of treatment to determine if it meets medical necessity criteria |
| Medical Necessity | The standard for whether treatment is clinically justified and appropriate |
| Evidence-Based Treatment | MCOs may require use of treatments with demonstrated effectiveness |
| Session Limits | Many plans limit the number of sessions covered per year |
| Co-pays and Deductibles | Client's out-of-pocket costs for each session |
| Out-of-Network | Providers not contracted with the insurance plan, often resulting in higher client costs |
CPT Codes for Psychotherapy Billing
Current Procedural Terminology (CPT) codes are used to bill insurance companies for psychotherapy services:
| CPT Code | Description |
|---|---|
| 90791 | Psychiatric diagnostic evaluation (intake assessment) |
| 90834 | Individual psychotherapy, 45 minutes (most common) |
| 90837 | Individual psychotherapy, 60 minutes |
| 90847 | Family psychotherapy with patient present |
| 90846 | Family psychotherapy without patient present |
| 90853 | Group psychotherapy |
| 90832 | Individual psychotherapy, 30 minutes |
| 96127 | Brief emotional/behavioral assessment (e.g., PHQ-9, GAD-7) |
Billing Ethical Considerations:
- Bill only for services actually provided
- Use accurate diagnostic codes — do not "upcode" or assign a more severe diagnosis to justify services
- Clearly communicate fees, billing practices, and insurance limitations to clients
- Document all services provided to support billing claims
Which CPT code is used for a standard 45-minute individual psychotherapy session?
Telehealth Practice
Telehealth (also called teletherapy or telebehavioral health) has expanded significantly, especially since the COVID-19 pandemic. Social workers providing telehealth services must navigate additional ethical, legal, and clinical considerations.
Key Telehealth Requirements:
- State licensing compliance: You must be licensed in the state where the client is located at the time of the session, not just where you are located. Some states have temporary or permanent exceptions through interstate compacts.
- HIPAA-compliant platforms: Use only platforms that meet HIPAA security standards (encrypted, BAA in place). Consumer platforms like Zoom (basic), FaceTime, and Skype are generally NOT HIPAA-compliant.
- Informed consent: Must specifically address telehealth risks, benefits, limitations, confidentiality in a digital environment, and technology failures
- Emergency protocols: Establish a plan for managing crises remotely, including the client's physical location, local emergency contacts, and nearby emergency services
- Technology considerations: Assess client's access to reliable internet, private space, and appropriate devices
- Documentation: Note that the session was conducted via telehealth, the platform used, and the client's location
Clinical Considerations for Telehealth:
- Not all clients are appropriate for telehealth (e.g., actively suicidal clients, clients without a private space, children requiring in-person interaction)
- Nonverbal cues may be harder to read through a screen
- Cultural and socioeconomic factors may affect access to technology
- Some therapeutic modalities translate well to telehealth (CBT, MI), while others may be more challenging (EMDR, play therapy)
Clinical Documentation
Thorough clinical documentation is essential for legal protection, continuity of care, insurance reimbursement, and quality assurance. The SOAP note format is widely used:
| Component | Content | Example |
|---|---|---|
| S (Subjective) | Client's report — what they tell you | "I've been sleeping better this week but still feel anxious at work" |
| O (Objective) | Clinician's observations | Client appeared calm, good eye contact, speech normal in rate and volume |
| A (Assessment) | Clinical analysis and impressions | Client shows improvement in insomnia; anxiety remains at moderate level; PHQ-9 decreased from 14 to 10 |
| P (Plan) | Next steps and interventions | Continue CBT for anxiety; introduce workplace exposure hierarchy; next session in 1 week |
Documentation Best Practices:
- Document within 24 hours of each session
- Use objective, behavioral language — avoid subjective judgments
- Include relevant clinical details but avoid unnecessary personal information
- Record risk assessments, safety plans, and consultation notes
- Note any changes to the treatment plan and the rationale
- Keep records secure and compliant with HIPAA
- Retention: Most states require records to be maintained for 7 years after the last contact (longer for minors)
Match each SOAP note component with its description:
Match each item on the left with the correct item on the right
When providing telehealth services, a social worker must be licensed in:
Assigning a more severe diagnosis to a client than is clinically warranted in order to obtain insurance coverage for services is an example of:
A social worker documents a session using the SOAP format. Under which section would the social worker record that the client appeared tearful with slowed speech?
How long are social workers typically required to retain client records after the last contact?
Which of the following is NOT a requirement for HIPAA-compliant telehealth practice?