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1
Children's Documentation TrainingPart II
Presented By
Quality Management
11.15.2010
2
Training Goals
• Review Medi‐Cal requirements and County standards for completion of clinical documentation
• Provide documentation requirement updates
• Q & A and technical assistance
• Interactive group exercises
3
Training Outline
• Overview of the Mental Health Plan
• Clinical Documentation Review
• Clinical Assessment Package
• Progress Notes and Service Codes
• Billable versus Non‐Billable
• Resources and Contact Information
4
Overview of the Mental Health Plan
• County Vision / Mission / Principles
• Target Populations / Medical Necessity
• Commitment to Cultural Competence
• Language Requirements / Interpreting Services
5
Medical Necessity
Criteria that identify service need based on inclusion of specific signs, symptoms, and conditions and proposed treatment associated with mental illness
Sacramento County Target Population (Youth):
‐ MediCal
‐ Chapter 26.5 (AB3632)
‐ Healthy Families
‐ Uninsured Youth 1
6
Medical Necessity (cont’d)
Determination of Medical Necessity Requires:
– Inclusion of a Covered Diagnosis
– Established level of impairment
– Expectation that Specialty Mental Health Services is necessary to address condition
–And the condition would not be responsive to physical health care based treatment
7
Medical Necessity (Cont’d)
When recording a client’s problem, the clinician must document:
• Onset
• Frequency
• Duration
• Severity of Symptoms/Behaviors
• Functional Impairments
8
Medical Necessity (Cont’d)
If client does not meet
Medical Necessity, but meets
Service Necessity, you have up to 30 days to link the client to a more appropriate service. You may bill Case Management / Brokerage.
9
Service Necessity
Service Necessity involves linking a client to a Primary Care Physician or Community Service Provider to meet mental health or other service needs when Medical Necessity is not met.
10
AB 3632/26.5 Guidelines
• 26.5/3632 are services for children who have a significant mental health condition preventing ability to benefit from educational services
• Mental Health services are needed in order for the child to benefit from his/her education.
• 26.5 offers a range of mental health services, including school site counseling, weekly therapy, intensive in‐home counseling, and residential placement
11
3632/26.5 Guidelines
• Children’s Case Management Services (CCMS) determines 26.5 eligibility
• Providers must coordinate all services with CCMS and obtain approval from CCMS PRIOR to service level changes or case closure
• The IEP directs the delivery of all mental health services and is required for discontinuation of mental health services and any changes in the level of care
12
3632 Handouts
• 3632 Services Frequently Asked Questions Handout
• 3632 Documentation Requirement Matrix (steps to take when funding source has changed)
• Provider training available through CCMS
The County is legally responsible for ALL services on the IEP. Services discontinued and still reflected on the IEP can result in legal repercussions for the
County.2-2B
13
Definition of Cultural Competence
A set of congruent practice skills, behaviors, attitudes, and policies that come together in a system, agency, or among consumer providers and professionals that enables that system, agency, or those professionals and consumer providers to work effectively in cross‐cultural situations.
14
Cultural/Linguistic Requirements
• Clients have a RIGHT to culturally and linguistically appropriate services
• Provide oral and written communication in the client’s preferred language and document each accommodation
• Must not expect family members to act as interpreters for a client or caregiver; document attempts to accommodate cultural and linguistic needs.
3
15
Culture and Services
• Recognize the link between culture and life experiences such as trauma and discrimination, and potential impact to mental health, when assessing, developing a treatment plan, and selecting interventions.
• Review literature, seek consultation, and be willing to learn about your client’s culture.
16
Interpreter Services• Southeast Asian Assistance Center (SAAC) 916‐421‐1036 or Outside provider agencies including Language World (916‐473‐0100) and Carmazzi (916‐714‐7848)
• Pacific Interpreters 1‐866‐425‐0217 (County staff to only use Pacific Interpreters for telephone interpreters and will need Assigned Access Code)
• Contract Providers may also use the AT&T Language Line
17
Services for Deaf/Hard of Hearing
• For Deaf/Hard of Hearing: A Show of Hands (916‐247‐8859), Class Act Alliance (916‐759‐4594), Sign Language Interpreting Services Agency (916‐483‐4751), or NorCal Services for Deaf and Hard of Hearing (916‐349‐7525)
18
COMPLIANCE PLAN
• According to CFR 42 (Code of FederalRegulations) & Title 9 Section 1840.112, it is required that all providers of mental health services verify that every service provided is accurately documented, signed and billed appropriately.
• Assessments, progress notes, and client plans are required documentation.
19
Consents and Releases
• Obtain legal guardian consent to treat for all minors as required by law.
• HIPAA compliant Authorizations required to Obtain or Release Health Records.
• A current medication consent is required for each medication the client is taking.
20
Clinical Documentation
• Client Data Sheet
• Assessment Client Plan (ACP)
• Re‐Assessment & Re‐Authorization (R&R)
• Child/Youth Health Questionnaire & Update (CHQ and Update)
• Progress Notes
• Discharge Re‐Assessment Summary
• Annual Medication Service Plan (if app.)
Use Forms with AVATAR logo
21
A Complete Clinical Assessment Packet Consists of:
• Client Data Sheet (CDS)
• Assessment Client Plan (ACP)
• Child Health Questionnaire (CHQ)
22
Paperwork Cycle SampleAuthorization
PeriodProvider Start Date
Clinical Assessment
Packet
1 year Initial Re‐Authorization Paperwork
6 month Re‐Authorization Paperwork
5/15/2009 ‐4/14/2010
5/28/2009
First face‐to‐face billable service
Due 7/28/2009
Complete within 60 days of
Provider Start Date
Due 3/31/2010 Re‐Auth Due 15 days prior to Auth End Date; (4/14/2010)
Due 9/29/2010 Re‐Auth Due 15 days prior to Auth
End Date
(10/14/2010)
Generated by The Child & Family Access Team
Complete:
ACP
CHQ
CDS
AMSP (If App.)
No Access Submission Requirements
Complete:
R&R
CDS
CHQ Update
AMSP (If App.)
Complete:
R&R
4
23
Access Screening and Admit
• Access Team screens to ensure minimum threshold for medical necessity is met and to rule out imminent risk
• Access admits child/youth to a Provider for up to 3 face‐to‐face Assessment Sessions, or for 60 days, whichever comes first, to confirm that medical necessity is met.
24
Establishing Medical Necessity
• Provider expected to document that medical necessity is met in first Assessment progress note, generally first face‐to‐face session with client
• If medical necessity is not established in 3 face‐to‐face assessment sessions, Provider completes and faxes the Discharge Re‐Assessment Summary to Access confirming that medical necessity is not met
25
Authorization Process
• Providers must submit an Authorization Packet to Access prior to the 4th face‐to‐face session; Packet includes: Managed Care Authorization Request; AVATAR Client Service Report; Copy of Clinical Progress Note establishing that medical necessity is met, including diagnosis and level of impairment.
26
Admission Billing
• First face‐to‐face session with child/youth should always be billed as Assessment and other services such as Collateral and Case Management Brokerage may be provided in addition to 3 face‐to‐face sessions to support the Assessment during the Admission period.
27
Start Dates and Billing
• Provider Start Date is established based on first face‐to‐face session, which is first billable service
• Limited exceptions to first face‐to face are allowed to meet urgent client needs
• See supervisor and CATS/Avatar Transition principles Document 3 for description of exceptions
5
28
Provisional Diagnoses and Avatar
• Every service claimed to Medi‐Cal must be supported by an included diagnosis to establish medical necessity (799.9 Deferred is not an included diagnosis)
• Basis for first provisional diagnosis is Access referral, first face‐to‐face contact and other collateral information (inpatient discharge record, previous treatment history, etc)
• Provider takes responsibility for Diagnosis upon opening case and establishing Start Date; Diagnosis source must be your agency LPHA, not Access team or outside source
• Provisional diagnosis can be changed over time
29
Service Coordination Requirements
• Referrals to Access for a step up/down, must include the ACP, most recent R&R, and CHQ or update
• The Access generated “Assignment of Service Coordinator” form must be in the child’s chart
• A treatment planning meeting between the closing and new provider, family, and other involved parties should take place within the first 30 days of the new provider assuming the case
• A Treatment Planning Meeting must take place PRIOR to submission of ACP/R&R, and at Paperwork Renewal Cycle when there are multiple providers
30
Client Data Sheet
6
31
When to complete CDS:
• Complete CDS at start of service along with ACP & CHQ
• Complete CDS at annual paperwork cycle along with R&R & CHQ Update
• Complete CDS when diagnosis, address, or other pertinent information changes AND remember to update in AVATAR
32
Assessment Client Plan (ACP)
7
33
Key Assessment Points1. Reasons for service includes current
symptoms, behaviors, and level of functioning to support Medical Necessity
2. Identify risks and follow‐up with a safety plan on summary section of ACP, page 6.
3. Provide cultural accommodations
4. Update physical health conditions and document all linkage
34
Key Assessment Points
5. Mental health history
6. Substance Use; remember secondary diagnosis and inclusion of at least one treatment goal, if appropriate
7. Current Psychiatric Medications
8. Five Axes diagnosis from DSM‐IV TR with Corresponding ICD‐9 Code for the Primary Axis I diagnosis. LPHA is the Diagnosis Source and not the DSM‐IV.
35
Member Handbook & Problem Resolution Guide
• Provide and review Member Handbook and Problem Resolution Guide to client and care giver at start of service and review annually thereafter and as requested by the client
• The Handbook and Guide are available on the QM Web Site in all Sacramento County threshold languages
Link to handbooks, posters and literature:http://www.sacdhhs.com/article.asp?ContentID=1399
36
Comprehensive 0‐5 ACP
• The 0‐5 ACP is used for children from birth until the child’s fifth birthday
• This 0‐5 ACP includes questions to meet the assessment needs of this age group
• The 0‐5 Crosswalk with DSM‐IV, a supplement to the DSM with age relevant symptoms, may be helpful when formulating a diagnosis
1
37
What are the differences?
• Some sections request Primary Caregiver information (mental health and substance use/abuse), Psychosocial History explores interactions between caregiver and child (early experiences and patters), and the Mental Status Exam requires more expanded observation of the child when responding to questions (self regulation).
38
0‐5 Re‐Authorization
• Re‐Authorization requests are completed using the 0‐5 ACP, with emphasis on current functioning and changes since the last assessment. There is no R&R for this age group.
39
TREATMENT PLANNING
40
Life Goals vs. Treatment Goals
• Life Goals are actual quotes or statements indicating hopes, dreams or ambitions. The life goal may or may not be related to the mental health condition.
• Treatment Goals are specific and measurable, developed with the client and caregiver, and address mental health symptoms and behaviors.
41
Treatment Goal Requirements• Specific and Measurable
• Type of Intervention
• Child/Youth/Family Strengths and Challenges
• Document responsibilities, including what the:• Child/Youth will do;
• Support person will do;
• Program staff will do;
• Document anticipated service resolution date• The Plan should be clear and will guide treatment
42
Treatment Goal Selection
• Address mental health symptoms, behaviors and functioning
• Collaborate with client and caregiver• Consider culture and diversity• Clients receiving 26.5 services require one goal related to a mental health barrier impeding educational achievement
• Substance use goal if appropriate and always secondary to mental health goals
43
Monitor Treatment Progress
• Services are driven by the treatment plan and progress notes should routinely reflect progress, challenges, or barriers
• Refer back to the plan regularly to ensure that all parties carry out their assigned responsibilities
• Adjust or select new interventions as determined by clinical need and status toward goal achievement.
44
Treatment Plan
• Client (10 yrs‐older) and caregiver signatures are required as evidence of participation; if no signature, use space on form to document reason for no signature and continue to document efforts to obtain signature(s)
• Provider signature required within the 60‐day timeframe, including co‐signature if required
45
Essential R&R Elements:
1. Current Medical Necessity2. Current Level of Functioning3. Current Need for Services4. Identify Updates/Changes from ACP5. Progress Towards Treatment Goals;
Identify if continuation
Submit to Access 15 days prior To Authorization expiration 8
46
R&R Completion
• Coordinate completion of R&R with Access and submit 15 days prior to authorization expiration.
• Involve client and caregiver in treatment planning, including initial, annual update, and whenever adjustments are made.
47
Child Health Questionnaire (CHQ)
Important Elements of CHQ/Updates
• Use CHQ Update at time of annual assessment completion and upon transfer
• Document reason in progress note for items left blank or marked “unknown”
• Follow up with identified needs and document all healthcare linkage in a progress note
48
Group Exercise
Sample Case Eduardo
9
49
PROGRESS NOTES OVERVIEW
50
Progress Notes
• Key topics discussed in the session
• Current symptoms and behaviors, including clinical findings and interpretations
• Accommodate language and culture
• Describe how interventions are addressing the client’s mental health condition and include client response
51
Progress Notes (Cont’d)
• Link between services and treatment plan
• Progress made toward achieving treatment goals, including strengths and challenges
• Always assess for risks and document actions taken to ensure safety
Note: Federal/State law require documentation for purposes of reimbursement. If records are inadequate or nonexistent, reimbursement is subject to recoupment.
52
Service Codes
• See Service Code Definitions/Training Guidefor master list of codes, definitions, and progress note examples
• It is responsibility of provider to enter services accurately in Avatar in accordance with contractually specified services and codes
• Consult your supervisor, Quality Management and/or contract monitor for clarification
53
Clinical Introductory Note
Written at first visit, or very soon thereafter, summarizing the client’s mental health condition and service needs. A complete note includes but is not limited to:
• Identity of client, including age, ethnicity, etc.• Referral Source• Cultural accommodations• Presenting condition, including symptoms, behaviors, and level of functioning
• Need for Services and Medical Necessity support• Client strengths, supports and challenges• Plan for services 10
54
• Collateral
• Assessment
• Individual Therapy
• Group Therapy
• Group Session
• Rehabilitation
• Plan Development
• Therapeutic Behavioral Services
• Medication Support
• Case Management Brokerage
• Crisis Intervention
• Cancellations
• No Shows
Types of Progress Notes
AVATAR Service Codes 5/27/2009 (Note: Lockout Codes) 11, 12
55
Collateral 95010
• Service to a significant support person for the specific purpose of helping the client meet mental health goals identified on the treatment plan
• The client may or may not be present for service
• The significant support person should be included in the plan
Note: Medi‐Cal will NOT reimburse for services that address the support person’s mental health issues.
56
Sample Collateral Note
Writer met with foster parent and teacher at school to discuss client’s progress on behavioral goals. Reviewed and compared tracking sheets used to assess progress. Determined situations where foster parent could increase limit setting and consequences to reduce client’s angry outbursts, as client has responded well to these interventions at school. Foster Mother supportive of implementing behavioral modifications discussed today. Plan to continue collaborative work with foster parent so that client may continue to remain at this school and in his current foster home. ‐ Joan Smith, MFT
57
Assessment Code 93010
• Evaluate current behavioral health and level of functioning
• Assess for medical necessity, includes conducting a MSE, gathering clinical and diagnostic history, etc.
• Accommodate for language and culture• Used to complete ACP, R&R, and as appropriate
• Use of Testing Procedures• Note: For 3632 only clients must use Assessment or Case Management code instead of Plan Development
58
Sample Assessment Note
Met with client and Mother, who prefer Spanish, and bi‐lingual writer accomodates. Client is a 14 y.o., Hispanic male, eldest of 4 children, referred due to history of trauma and aggressive behavior at school. Father unemployed after lay‐off 8 months ago and Mother works part‐time. Family has unpaid bills and is struggling financially. Client admits to some alcohol use with friends; denies gang involvement. Gathered psychosocial history, explained services, problem resolution, confidentiality, etc. Plan: Continue to assess, including role of cultural values and beliefs, and develop plan… – Sergio Vasquez, MFT
59
Individual Therapy 97010
• Psychotherapeutic intervention to improve symptoms, increase level of functioning, and support developmental progress
• Guided by the treatment plan, completed prior to start of therapy
• Only an LPHA, or a graduate student trainee under the supervision of an LPHA, may provide individual therapy
60
Individual Therapy Note
Met with client for individual session. Focus today is client’s recent alcohol use, resulting in near collision with a car while client was biking home. No alcohol use since incident, per client report. Writer uses Cognitive Therapy to explore precipitants to alcohol use, peer pressure, social insecurities, and “non stop” stress at home, followed by discussion of ways to manage these situations. Client is receptive and, though expresses some reluctance, is willing to abide by parental curfew and try strategies we discuss today. Plan: Appt scheduled for next week with client.
‐ Phil Yang, MFT
61
Group Session vs. Therapy
Group Sessions are Rehabilitative or skill building groups provided by licensed and unlicensed staff.Group Therapy provides a clinical approach to topics such as Depression and Anxiety and are provided by licensed or licensed waived staff.
• Group Session is NOT reimbursable for 3632 only clients
62
AVATAR Multiple Client Charge Input
AVATAR calculates the units billed. The Group Formula is no longer used. The Practitioner completes the Multiple Client Charge Input (one per Group). No other charges are listed. Designated staff enter data into AVATAR, where the number of units billed are calculated. Reports are available in AVATAR to verify units billed.
63
Group Progress Notes
A group note should include:–Type/Title of group
–Goal/Focus of today’s group
–Client’s receptivity or response in group
– If co‐facilitated, each staff member’s role must be documented as distinct, unduplicated and necessary
(In order to count as a “group” at least 2 clients for “one staff” is needed)
64
Sample Group Session Note
This writer facilitated a social skills building group for boys with focus on conflict resolution. All participants have had a teacher or administrator intervene to arbitrate or manage a conflict. Client actively participated in today’s group activity and was able to listen without interruption. Writer role played scenarios showing how to cooperate and negotiate and also practiced using conflict resolution skills. Client listened, observed and successfully used conflict resolution skills during group role play exercises. Plan: Contact client’s teacher for update on behavior displayed in classroom. ‐Michael Rogers, MHRS
65
Discussion of AVATAR Group Note
Screen fields for discussionService Type: 1‐Mental Health SvcService Code: 96520Practitioner Name and Staff IDTime: Service=120 Doc=48, Travel=0, Total= 168 The Client Service Report will show the total billing unit number
EBP/SS(1), etc. Number of Clients: 6
13
66
Co‐Facilitated Group Note (AVATAR)• This writer co‐facilitated a mixed gender social skills group
emphasizing peer relationships and socialization skills. The focus of today’s group was on interacting in public settings such as grocery stores or restaurants. Writer and the co‐facilitator split the group into male and female members and role played several examples within the groups and then brought them back together for discussion and more role playing.
• Client participated actively in today’s group and interacted positively with peers. Client said that she enjoyed the group and that it actually helped to alleviate some of her anxiety in dealing with social situations. The group will meet again nextWednesday, 2pm.
• Joe Therapist, MHRS
67
Discussion of AVATAR Group Note
Screen fields for discussion:Service Type: 1‐Mental Health SvcService Code: 96520 Practitioner Name and Staff IDTime: Service=120, Doc=30, Travel=30, Total=180Co‐Practitioner Name and IDTime: Service=120, Doc=20, Travel=0, Total=140EBP/SS(1), etc. Number of Clients: 5
14
68
Rehabilitation 94000
• Assisting a client in improving, restoring or maintaining:– Functional skills– Daily living skills– Social skills– Grooming and personal hygiene skills– Meal preparation skills
• Counseling of the client and/or family• Notes should reflect interventions, progress and response to
skill training• Rehabilitation is not reimbursable for 3632 only clients.
69
Rehabilitation Note
Met with 19 year‐old client at supermarket to continue skills training and support with budgeting and independent living skills. Assisted with developing shopping list for purchasing foods and household items. Guided client regarding purchasing foods for meal preparation and balanced diet. Coached client and modeled interaction with store employees. Client was able to appropriately ask for assistance from store clerks. Plan: Will continue working with client on independent living skills next session.
– Katherine Fong, MHAII
70
Plan Development 98500
• Service activity involving the development and implementation of a plan or intervention
• Progress Note must clearly document steps for a planned intervention and follow‐up
• Plan development is not reimbursable for 3632 only clients
71
Sample Plan Development Note
Met with client and mother for treatment planning session. Worked collaboratively to develop treatment goals related to Life Goal of going to college and becoming a lawyer. Client expresses interest in improving concentration and reducing depressive episodes that interfere with school. See ACP for treatment goals and supporting information. Plan: Continue rapport building and developing treatment goals together.
– Melissa Wright, LCSW
72
Therapeutic Behavioral Services94030 / 94040 / 94050
• Must be pre‐authorized by the Child and Family Access Team
• TBS Treatment Codes should be billed ONLY when 1:1 service is provided
• Progress Notes and Treatment Plans must specify a target behavior
73
TBS Eligibility• Full Scope Medi‐Cal beneficiary under 21 years old
• Must meet MHP Medical Necessity Criteria• Must be a certified class member by meeting one of the following criteria
Placed in group home/RCL 12 or higherAt least 1 psych hospitalization within 24 monthsBeing considered for placement in a group home/ RCL 12 or higherPreviously received TBS while a certified class member
74
Medication Support97500 / 97530
• Only MDs, RNs, LVNs, and PTs can bill these services.
75
Case Management/Brokerage 94510
76
When to Bill Case Management Brokerage?
Linkage to:
‐Primary Healthcare Services
‐Other Mental Health Services
‐Non Mental Health Services
• Co‐staffing for intra/inter agency purposes must be non‐supervisory, non‐duplicative, with meaningful planning and implementation
• Note: For 3632 only clients the Assessment or Case Management treatment code may be used for Plan Development services
77
Sample Case Management Note
Writer called client’s Probation Officer, Mike Jones (Release/Info is on file) to assist in coordinating group home placement. Mr. Jones requested information regarding client functioning, mental health history, strengths, and challenges that may affect success of proposed placement. Current plan is for client to step down to lower level RCL 12 placement by March 31.
‐Cindy Mendoza, LCSW
78
Psychiatric Hospital &Targeted Case Management
Solely for purpose of coordinating placement at time of discharge from hospital, psychiatric health facility or psychiatric nursing facility “may be provided during 30 calendar days immediately prior to the day of discharge, for a maximum of three non‐consecutives periods of 30 calendar days or less per continuous stay in the facility”.
79
Elements of Targeted Case Management Progress Note
Projective date of Discharge
Consultation and participation on discharge plan as relating to placement needs of client
Monitoring and Follow up Activities regarding transitioning from inpatient to discharge
Dates, Staff Signatures and Client Service Information (CSI) data information
Bill to 94510Handouts
80
Co‐Bill Progress Note (AVATAR)Writer consulted with program housing specialist, John Wilson, regarding strategy and resources for client who recently lost housing. Discussed options for emergency and short‐term placement as well as other support services for client and family during crisis. Writer will adjust treatment plan to focus on housing and emergency needs until situation is stabilized. John agreed to meet with client to assist with applications for emergency placement tomorrow afternoon. Writer contacted client to update on plan and confirm appointment tomorrow.
• Joe Therapist, MHRS16, 16A
81
Co‐Billing Case Consultation
The Practitioner seeking consultation will generally write the Progress Note. Include the following elements to support co‐billing: • Identify who the Practitioner consulted with
(Role/Expertise and, if applicable, Licensure) and purpose of consultation
• Succinct summary of consultation;• Describe benefit to client from the consultation• Plan of action resulting from consultation
This Practitioner will also complete the Multiple Client Charge Input.
82
Crisis Intervention 95510
83
When to Bill for Crisis Intervention
• For unplanned events that require immediate risk assessment and response to alleviate problems which, if untreated, present an imminent threat to the client or others
• When immediate response is needed to help the client stabilize and maintain in a community setting
• For development of safety plan for current and future circumstances
84
More Crisis Billing
• Services are typically face‐to‐face with client, however may also be by telephone with client or significant support person
• Services may be provided anywhere in the community
• May require multiple service activities, under the umbrella of crisis to bring the situation to resolution
• Crisis billing must stop once the crisis is resolved, however it may be appropriate to bill another service activity if continued services are provided
85
Sample Crisis Intervention NoteWriter travels to client’s school at teacher’s urgent request. Per report, client says she began feeling “spacey and unreal,” and a few days ago started hearing the voice of a woman crying for help; client says she looks to see the woman, but no one is there. Client also shared with teacher feeling guilty that she causes her parents conflict and that, if she just “disappeared”, perhaps they would “stay together.”Writer assesses risk and client shares hearing and believing a voice telling her she “should die.” Client responding to internal stimuli, however she is calm and willing to go to MERT with writer. Yoshiko Sumi, MFT
86
Discharge Re‐Assessment Summary
• White document filed with the pink Progress Notes and considered the final progress note.
• Documents evaluation of treatment progress to support discharge; includes current functioning, treatment recommendations, referrals, and closing observations
• Type of billing code used is determined by type of service provided to the client in the session. If no service is delivered the note is non‐billable.
87
Administrative Discharge Re‐Assessment Summary Note
Client began no‐showing for services two months ago and efforts to make contact with family have been unsuccessful. Writer will close case. Reviewed case file, noting client’s progress demonstrated by improved grades, completion of chores at home, and no truancy for 3 months and completed all case closure documents. James Bradley, LCSW
88
Discharge Re‐Assessment Summary Bill to Individual Therapy
Met with client for final therapy session. Discussed progress made toward treatment goals and strategies for maintaining progress. Focused reinforcement of strategies learned and practiced, with success, as demonstrated by client’s increased attention span, decrease class room interruptions, and increase in appropriate peer interactions. Praised client’s hard work and motivation to, as client states: “keep up the good work.” Client will continue medication management through primary care physician. Verna Silva, IMF
89
Annual Medication Service PlansAMSP
Coordinating Medication Services with the Psychiatrist
90
Essential AMSP Elements
• An AMSP must be completed at the time a psychiatrist initially prescribes or evaluates current medication and annually thereafter.
• A Psychiatrist is not required to see a child for the sole purpose of completing an AMSP. Annual Completion of the AMSP can be done at the next face to face appointment if no psychiatric services were provided between due date and the next visit.
91
Essential AMSP Elements (Cont’d)
• An AMSP must be completed upon a 2nd medication evaluation appointment when no medication has been prescribed but a 3rd planned medication appointment is scheduled for further assessment.
• It is not uncommon for a child psychiatrist to need more than one visit to determine a course of treatment.
92
Situation #1 Billable?
You receive a voice mail from client’s mom who states that her son needs to see you sooner.
Sample Documentation: Received call from mom requesting an earlier appointment as soon as possible. Returned call, spoke to mom, and rescheduled appointment for earlier date.
17
93
Situation #2 Billable?
You submit a TBS referral to ACCESS
Sample Documentation: Writer completed TBS referral and faxed to ACCESS for review.
17
94
Situation #3 Billable
You take client on an outing to a King’s Game to practice social skills.
Sample Documentation: Writer took client to a King’s Game. Client watched the game with interest and seemed to enjoy the activity.
17
95
Situation #4 Billable?
A CPS worker leaves a message requesting a report on how client is doing in treatment.
Sample Documentation: CPS worker left message requesting a written report on client’s progress. Wrote updated reports for social worker and faxed to her as requested.
17
96
Document non‐reimbursable services but do not bill
Examples:
• No Shows
• Supervision
• Transportation
• Administrative Activity
Non‐Reimbursable Services
97
Supervision – non‐billable
vs.Consultation ‐ billable
• Supervision: time spent providing supervision to staff/students for the purpose of:– Obtaining BBS required clinical hours, and/or – To monitor/manage a clinician’s learning curve.
• Consultation: Inter/Intra agency communication and coordination with an experienced professional for the purpose of improving treatment and planning interventions.
98
Transportation – non‐billable
vs.Billable Travel ‐ billable
• Transportation: Physically taking clients from one place to another.
• Travel Time: The time spent traveling to/from a service site where a mental health service was provided.
99
When NOT to Bill
• Billing for second staff when the roles appear duplicative, non‐essential, or inappropriate for the individual service or group (note Case Management is the only code that may be co‐billed; 2 staff may not bill for Assessment, Individual Therapy, etc.)
• Excessive billing for chart review with no documented product such as updated plan or concrete outcome resulting from the review
• Providing mental health counseling or services for someone other than the beneficiary
• Providing interpretation services
100
Service Request Form
All services go through the
Child and Family Access Team
Phone: 875‐9980
Fax: 875‐9970
101
Matt Quinley 875Matt Quinley 875‐‐98829882, [email protected]
Melody Boyle 875‐6280, [email protected]
Documentation/Utilization Review Contacts
102
Problem Resolution Contact
• Rolanda Reed‐Anning, 875‐0853,
Reed‐[email protected]
• Member Services: 888‐881‐4881
916‐875‐6069
916‐876‐8853 (TTY)
103
Additional Contact Information
• MHSA QM Questions: – Matt Quinley, 875‐9882 [email protected]
• 3632: – Donna Coy, 875‐9871 [email protected].
104
Web Sites
• http://www.sacdhhs.com/article.asp?ContentID=281Link to QM/UR topics for provider information, children’s documentation training questions & answers, QM training calendar etc.
• http://www.sacdhhs.com/article.asp?ContentID=1345Direct link to Quality Management Policies and Procedures.
• http://www.sacdhhs.com/article.asp?ContentID=1399 Link to problem resolution member handbooks, posters and literature
105
The End