Therapy Glossary
Your comprehensive guide to therapy terminology, billing codes, documentation standards, and compliance requirements.
BAA
Business Associate Agreement - A legally binding document between a healthcare provider and a business associate that handles PHI, required under HIPAA.
CBT
Cognitive Behavioral Therapy - A form of psychological treatment that helps patients understand the thoughts and feelings that influence behaviors.
CPT Code
Current Procedural Terminology Code - A standardized code used to describe medical, surgical, and diagnostic services for billing purposes.
DAP Note
Data, Assessment, Plan - A documentation format for clinical notes that organizes session information into three sections.
DBT
Dialectical Behavior Therapy - A type of cognitive-behavioral therapy that combines strategies like mindfulness and distress tolerance.
DSM-5
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition - The standard classification of mental disorders used by mental health professionals.
EAP
Employee Assistance Program - A work-based intervention program designed to help employees deal with personal problems that might adversely impact their work.
EHR
Electronic Health Record - A digital version of a patient's paper chart that contains the patient's medical history, diagnoses, medications, and treatment plans.
EMDR
Eye Movement Desensitization and Reprocessing - A psychotherapy treatment originally designed to alleviate the distress associated with traumatic memories.
EOB
Explanation of Benefits - A statement from a health insurance plan describing what costs it will cover for medical care or products received.
GAD
Generalized Anxiety Disorder - A mental health condition characterized by excessive, uncontrollable worry about everyday events and activities.
Good Faith Estimate
A document required by the No Surprises Act that provides uninsured or self-pay patients with an estimate of expected charges for scheduled services.
HIPAA
Health Insurance Portability and Accountability Act - Federal law that protects sensitive patient health information from being disclosed without consent.
ICD-10
International Classification of Diseases, 10th Revision - A medical classification list by the WHO containing codes for diseases, symptoms, and procedures.
Informed Consent
A process by which a patient is informed about all aspects of their treatment and gives their voluntary agreement to proceed.
Intake Assessment
The initial evaluation conducted when a client begins treatment, gathering comprehensive background information and presenting concerns.
LCSW
Licensed Clinical Social Worker - A mental health professional who has earned a master's degree in social work and has met state licensure requirements.
LMFT
Licensed Marriage and Family Therapist - A mental health professional who specializes in family systems and relationship dynamics.
LPC
Licensed Professional Counselor - A mental health professional who has earned a master's degree in counseling and has met state licensure requirements.
MDD
Major Depressive Disorder - A mental health condition characterized by persistent feelings of sadness and loss of interest that interfere with daily activities.
NPI
National Provider Identifier - A unique 10-digit identification number issued to healthcare providers in the United States.
PHI
Protected Health Information - Any individually identifiable health information held or transmitted by a covered entity or its business associates.
POS
Place of Service - A two-digit code used on healthcare claims to indicate where services were provided (e.g., 11 for office, 02 for telehealth).
Progress Note
Documentation of each therapy session that records the client's presentation, interventions used, and progress toward treatment goals.
PTSD
Post-Traumatic Stress Disorder - A mental health condition triggered by experiencing or witnessing a terrifying event.
ROI
Release of Information - A form signed by the client authorizing the release of their protected health information to specified parties.
SOAP Note
Subjective, Objective, Assessment, Plan - A documentation method used by healthcare providers to write notes in a patient's chart.
Superbill
An itemized form used by healthcare providers to submit claims to insurance companies or to give clients for out-of-network reimbursement.
Telehealth
The delivery of health-related services and information via electronic information and telecommunication technologies.
Treatment Plan
A written document outlining the client's diagnosis, treatment goals, objectives, and interventions to be used in therapy.
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