Couple or Family Charts

Clinicians who engage in Couple or Family therapy can handle couples therapy in two ways. Option 1 includes a patient chart, note, and billing for the primary partner or family member only, whereas option 2 includes a patient chart, note, and billing for both partners or family members.

Option 1 

Create a patient chart, complete notes, and bill for the primary partner or family member only

1. Add Primary Patient Chart 

Decide which person in the couple serves as the primary patient.  (You could have them flip a coin). If you are not billing insurance, the patient first name could be ‘John and Mary’ and the patient last name could be ‘Jones’ or ‘Jones and Johnson” If you ARE billing insurance, the name entered must be the name of the identified patient. The ‘nick name’ on the profile could be ‘Mary and John’ or ‘Family’

2. Scheduling Appointments 

3. Schedule the patient on your schedule as you would any client.

4. Notes 

Complete the note that corresponds with the scheduled appointment. It is recommended that in the note narrative, you include information about who was in attendance at the appointment that day.

5. Billing 

Once the appointment is concluded and you have either accepted payment or started a note, the client account will be billed for the service accordingly.

Option 2

Create a patient chart, complete notes, and bill for both partners or family members

1. Add Patient Chart for Both Partners or Family Members 

2. Add each member of the couple or family as an individual patient. Next, create a ‘family group’ by going to ‘My Clients’ / New Group. Name the group something appropriate such as ‘Jones Family’. This group name only has to be meaningful to you – not to the client. Now assign each member of the family to the group. Set up the cpt code that you will be charging the members. For Additional Information on setting up and charting on groups, Click Here. 

3. Scheduling Appointments 

Schedule the couple/family appointment by selecting the group name when clicking in the time slot.

4. Notes 

Complete the corresponding group therapy progress note for each member of the family. Be sure to document the parties names who were in the counseling session.

5. Billing 

Once the appointment is on the schedule the system automatically generates a billing line item in each partner’s chart under the “Patient Billing” tab. If you did not intend to bill each patient for the session, go to the family members accounts you did not wish to charge and edit the invoice line item to be a $0.00 (zero) dollar charge for the session, but leave the cpt code for the session intact. 

Things to think about from a perspective of a Marriage and Family Therapist on this topic from Denise Hoyt, LMFT:

If I were keeping a paper record on a couple or a family, I would have ‘one folder’ to hold all of the notes, because the ‘couple’ or the ‘family’ is my client – not the individual member of the party. Also, I am ethically bound to NOT release any couple or family records without written consent of ALL parties involved. By using Option 1, I am reasonably protecting myself if there is a request to release records, because it’s obvious this was a couple/family session. By using option 2, it means that if I’m not careful and there’s a record request by an individual in that family, that I may not realize that there are other parties involved in the session, and if I released records, I could be breaching my professional ethics and state laws.  

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