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CALIFORNIA CODE OF REGULATIONSTitle 22 Drug Medi-CalSection 51341.1-effective 6/25/14
PRESENTATION OUTLINE
I. Admission/Physical Exam
II. Treatment Planning
III. Counseling Sessions
IV. Progress Notes
V. Continuing Services
VI. Discharge
VII. Additional Requirements
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DMC BackgroundDrug Medi-Cal (DMC) is a drug and alcohol treatment program funded through the federal Medicaid program
The services provided must be contained in an approved State Medicaid Plan (approved by CMS)
The California Federal Financial Participation (FFP) is 50% federal funds and 50% state or local funds
The primary regulations that govern DMC are contained in Title 22, Sections 51341.1 (program requirements), 51490.1 (claim submission requirements) and 51516.1 (reimbursement rates and requirements)
Program Integrity emergency regulations for Section 51341.1 became effective on 6/25/14
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DRUG MEDI-CAL SUD TREATMENT SERVICE MODALITIES
Outpatient Drug Free (ODF)ODF Regular and Perinatal
Day Care Habilitative (DCH)DCH EPSDT and Perinatal
Perinatal Residential Substance Abuse
Naltrexone
Narcotic Treatment Programs will not be
addressed in this presentation
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JOB ONE!
Know and follow the regulations
WHY? ClientsFunding
Did I say Clients?
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Establish Medical Necessity (physician)
Establish and maintain individual Beneficiary record
Provide treatment services
Document, document, document
Submit claims for reimbursement
ANDThe Double Top Secret Magic Passwords to Success
Follow the TIMELINES in the regs
PROVIDER RESPONSIBILITIES
PROVIDER DON’TS
Do not sign patient names to any document or sign-in sheet
Do not sign any document using the Medical Director’s or anyone else’s signature (no signature stamps allowed)
Do not intentionally submit erroneous billings
Do not falsify any Medi-Cal record/document (e.g., progress notes, treatment plans, etc.)
Do not back date/forward date any signature
Sign blank documents
Do not allow unqualified staff to provide services
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Almost everything you
want to know about DMC
admission criteria
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ADMISSION TO TREATMENT
For each Beneficiary the provider shall complete:
Personal history
Medical history
Substance use history
Assessment of the physical condition
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ADMISSION CRITERIASection 51341.1(h)
INTAKE /ASSESSMENT
The Basis for Establishing Medical Necessity
The evaluation or analysis of the cause or nature of the disorders listed below using DSM codes:
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Mental Emotional Psychological Behavioral and Substance Use
Section 51341.1(b)(13)
The assessment of treatment needs to provide medically necessary treatment services by a physician includes
May also include a physical examination and laboratory testing by staff lawfully authorized to provide such services
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ADDITIONAL PERINATAL REQUIREMENTS
Sections 50260, 51303, 51341.1(c)(1), 51341.1(g)(1)(A)(iii)
Beneficiary must be eligible for and received Medi-Cal during the last month of pregnancy
Must have medical documentation that substantiates the Beneficiary’s pregnancy and last day of pregnancy.
Rate is applicable during pregnancy and for the 60-day postpartum period beginning on the last day of pregnancy
Eligibility ends on the last day of the month in which the 60 th day occurs
PHYSICAL EXAM REQUIREMENTS
A physical examination can be conducted by the program’s physician, registered nurse practitioner or physician’s assistant, within thirty (30) days of admission
OR
Physician can review documentation of most recent (within 12 months) physical examination
OR
Include obtaining a physical examination as a treatment plan goal
WHY IS A FOCUS ON PHYSICAL HEALTH IMPORTANT?
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Section 51341.1(h)(1)(A)(iv)(a)(b)&(c)
PHYSICAL HEALTH AND SUD
SUD complicates and leads to serious health conditions
Increased risk of pregnancy complications, cancer, and gastrointestinal, cardiovascular, pulmonary, renal, hematological, gynecological and metabolic problems.
Arthritis, asthma, hypertension and ischemic heart disease – 2x more prevalent in SUD patients
Over half of people w/SUD have another health condition
SUD has negative impact on mental health and behavior
Risk-taking behavior creates high risk for communicable diseases and other serious injury
People w/SUD incur 2x-3x the total medical expenses of people who do not have SUD
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Physical Examination Waivers are no longer an option for Drug Medi-Cal Programs
The physician shall document the basis for the DSM code diagnosis indicating medical necessity in the Beneficiary’s individual record within thirty (30) calendar days of the Beneficiary’s date of admission to treatment.
MEDICAL NECESSITY
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Sections 51303, 51341.1(h)(1)(A)(v) (vi)
TREATMENT PLANNING
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TREATMENT PLANNING Section 51341.1(h)(2)
The treatment plan for each Beneficiary must:
Be individualized
Be based on the information obtained during the intake and assessment process
Attempt to engage the Beneficiary to meaningfully participate in the preparation of the initial treatment plan and updated treatment plans – Bene must sign! If Bene refuses, documentation of strategy to engage Bene must be added to Tx plan.
Be legible – including staff names; names of counselors, therapists, physicians, etc. Must sign and date.
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MUST INCLUDE THE FOLLOWING EIGHT (8) ELEMENTS…
Section 51341.1(h)(2)(A)(i)
1) A statement of the problems to be addressed
2) Goals to be reached which address each problem
3) Action steps which will be taken by the provider, and/or Beneficiary to accomplish identified goals
4) Target dates for the accomplishment of action steps and goals
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EIGHT ELEMENTS Cont. Section 51341.1(h)(2)(A)(i)
5) A description of the services, including the type and frequency of counseling to be provided
Group counseling must be a specific number of sessions over a specific period of time
If individual counseling is planned, it must be on the treatment plan
6) The assignment of a primary therapist or counselor
7) The Beneficiary’s DSM code diagnosis
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LAST BUT VERY IMPORTANT8) If the Beneficiary has not had a physical examination within the twelve (12) month period prior to the date of admission, a goal that the Beneficiary have a physical examination must be added to the treatment plan.
AND If documentation of a Beneficiary’s physical examination,
which was performed during the prior twelve (12) months, indicates a significant medical illness, a goal
that the Beneficiary obtain appropriate treatment for the illness must be added to the treatment plan.
Therapist/Counselor - shall complete, sign and date the initial treatment plan within thirty (30) calendar days of the admission to treatment date.
Beneficiary – shall review, approve, sign and date the initial treatment plan, indicating whether the beneficiary participated in preparation of the plan, within thirty (30) calendar days of the admission to treatment date.
Physician - shall review the initial treatment plan to determine whether the services are medically necessary, sign, and date the initial treatment plan within fifteen (15) calendar days of signature by the therapist or counselor.
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INITIAL TREATMENT PLAN TIMELINES Section 51341.1(h)(2)(A)(ii)
Therapist/Counselor shall complete, sign and date the updated treatment plan no later than ninety (90) calendar days after signing the initial treatment plan, and no later than every ninety (90) calendar days thereafter (unless a change in problem identification or focus of treatment occurs)
The Beneficiary shall review, approve, sign and date the updated treatment plan, indicating whether the Beneficiary participated in preparation of the plan within thirty (30) calendar days of signature by the therapist or counselor.
The Physician shall review each updated treatment plan to determine whether the services are medically necessary and sign and date the updated treatment plan within fifteen (15) calendar days of signature by the therapist or counselor.
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UPDATED TREATMENT PLAN TIMELINESSection 51341.1(h)(2)(A)(iii)
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BENEFICIARY CONTACT REQUIREMENTS
Section 51341.1(d)(2)(A) (h)(4)(A)
Minimum of two provider/beneficiary contacts per 30 day period (for ODF – 2 group counseling sessions)
Requirement may be waived by the physician if:a) Fewer contacts are clinically appropriate;
b) The Beneficiary is making progress towards treatment plan goals
BENEFICIARY CONTACT Cont.
Exceptions must be noted, signed and dated by the physician in the Beneficiary’s record
However
If the Beneficiary does not attend treatment for more than 30 days, the provider must
discharge the Beneficiary.
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Covered So FarI. Admission/Physical Exam
II. Treatment Planning
III. Counseling Sessions
IV. Progress Notes
V. Continuing Services
VI. Discharge
VII. Additional Requirements
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GROUP COUNSELING
Section 51341.1(b)(11)
Must be conducted in a confidential setting
Must have a group sign-in sheet that includes:
A typed or printed list of the Beneficiary’s names and the signature of each Beneficiary that attended the counseling session
A typed or printed name and signature of counselor(s) facilitating session (certifying accuracy and completeness)
The date of the counseling session
The start and end times of the counseling session
The topic of the counseling session
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GROUP COUNSELING SESSIONS Sections 51341.1(b)(11), 51341.1(g)(2)
REQUIREMENTS BY MODALITY Section 51341.1(b)(11)
ODFMust have at least four (4) and no more than ten (10) participants in any one group counseling session
In order to bill DMC, at least one of the four (4) to ten (10) participants must be a DMC Beneficiary
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Must have at least two (2) and no more than twelve (12) participants in any one group counseling session
In order to bill DMC, at least one of the two (2) to twelve (12) participants must be a DMC beneficiary
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REQUIREMENTS BY MODALITYSection 51341.1(b)(11)
DCH
A Beneficiary that is under the age of 18 years cannot participate in group counseling sessions with any participants that are 18 years or older
UNLESSThe group counseling sessions are held at
a provider’s certified school site
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AGE LIMITS
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INDIVIDUAL COUNSELING
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INDIVIDUAL COUNSELINGSection 51341.1(b)(10)
Must be face to face contact at a DMC certified location to bill for the service
No home visits, no hospital visits, no telephone contacts
INDIVIDUAL COUNSELING LIMITS FOR ODF
Intake/Assessment
Treatment Planning
Discharge Planning
Collateral
Crisis
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COLLATERAL SERVICES COUNSELINGSection 51341.1(b)(4)
Face-to-face session
With persons significant in the life of the Beneficiary
Personal, not professional, relationships
Focusing on the treatment needs of the Beneficiary
Supporting the achievement of the Beneficiary’s treatment goals
Beneficiary does not have to attend
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CRISIS INTERVENTION COUNSELING Section 51341.1(b)(7)
Face-to-face contact with a Beneficiary in crisis
Crisis is an actual relapse, or
Unforeseen event or circumstance causing an imminent threat of relapse
Services shall:
Focus on alleviating crisis problems, and
Limited to stabilization of the emergency
PROGRESS NOTES
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Counselor/therapist must legibly print, sign and date
the progress note!
For each individual and group counseling session the therapist or counselor who conducted the counseling session shall record a progress note for each Beneficiary who participated within seven (7) calendar days of the session that includes the following:
The topic of the session
A description of the Beneficiary's progress on the treatment plan problems, goals, action steps, objectives, and/or referrals
Information on the Beneficiary's attendance, including the date, start and end times of each individual and group counseling session
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ODFSection 51341.1(h)(3)(A)
At minimum, one (1) progress note, per calendar week, should be recorded for each Beneficiary and should include:
A description of the Beneficiary's progress on the treatment plan problems, goals, action steps, objectives, and/or referrals
A record of the Beneficiary's attendance at each counseling session including the date, start and end times and topic of the counseling session
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DCH/PERINATAL RESIDENTIALSection 51341.1(h)(3)(B)
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Progress notes should tell the beneficiary’s treatment story
Covered So FarI. Admission/Physical Exam
II. Treatment Planning
III. Counseling Sessions
IV. Progress Notes
V. Continuing Services
VI. Discharge
VII. Additional Requirements
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To treat or not to treat,
That is the Question
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CONTINUING TREATMENT
MEDICAL NECESSITY OF CONTINUED SERVICES
Section 51341.1(h)(5)(A)(ii)
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No sooner than 5 months and no later than 6 months after admission, or the completion of the most recent justification, the need for continued treatment must be determined by the physician.
CONTINUED SERVICES JUSTIFICATION
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The physician must document the medical necessity determination to continue services based on review of the Beneficiary’s:
Personal, medical and substance use history
Most recent physical exam
Treatment plan goals
Progress in treatment (progress notes)
Therapist/counselor recommendations
Prognosis
DISCHARGE
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DISCHARGE PLANSection 51341.1(h)(6)(A)
Discharge Plans must be completed in the thirty (30) calendar days prior to the last face-to-face treatment session on all Beneficiaries by the therapist/counselor.
The Discharge Plan is a document developed by the counselor and the Beneficiary that identifies the Beneficiary’s
Relapse triggers
Support plan
The Discharge Plan must be signed by the counselor and the Beneficiary and a copy provided to the Beneficiary. The Discharge Plan will become part of the individual record.
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RELAPSE TRIGGERSSection 51341.1(b)(26)
SUPPORT PLANSection 51341.1(b)(28)
A list of individuals and/or organizations and activities that can provide support and
assistance to a Beneficiary to maintain sobriety.
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DISCHARGE SUMMARYSection 51341.1(h)(6)(B)
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When a provider has lost contact or the Beneficiary is not available for 30 days, the provider will complete a Discharge Summary that shall include:
Duration of treatment as determined by admission and discharge datesReason for dischargeNarrative summary of treatment episodeBeneficiary’s prognosis
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FAIR HEARING Section 51341.1(p)
Providers shall inform Beneficiaries of their right to a fair hearing related to:
Denial
Involuntary discharge
Reduction in DMC services
As these relate to their eligibility or benefits.
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FAIR HEARING Section 51341.1(p)
At least 10 calendar days prior to the effective date of the intended action the provider must give the Beneficiary a written notice that includes:
A statement of the action the provider intends to take
The reason for the intended action
A citation of the specific regulation(s) supporting the intended actionInforming the Beneficiary of his/her right to a fair hearing for the purpose of appealing the intended action
Informing the Beneficiary that the provider must continue treatment only if the beneficiary appeals in writing within 10 days of the notice
Must include the address where the request for a fair hearing must be submitted
Additional Requirements
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MULTIPLE SERVICES SAME DAYSection 51490.1
ODF Return visit shall not create a hardship on Beneficiary
Document time of day of each visitProgress note shall clearly reflect that an effort to provide all services in one visit was made and the return visit was unavoidable;The return visit shall clearly document a crisis or collateral serviceThe provider must complete the DHCS MC 7700 form and place in Beneficiary record
Or
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DCHThe return visit shall clearly document a crisis service
Crisis services shall be documented in the progress notes
Provider must complete the DHCS MC 7700 form and place in Beneficiary record
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MULTIPLE SERVICES SAME DAYSection 51490.1
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SHARE OF COSTSection 51341.1(h)(7)
Except where share of cost, as defined in Section 50090, is applicable, providers shall accept proof of eligibility for Drug Medi-Cal as payment in full for treatment services rendered. Providers shall not charge fees to a Beneficiary for access to Drug Medi-Cal substance use disorder services or for admission to a Drug Medi-Cal treatment program.
Contact DHCS Provider Enrollment with application and certification inquiries as well as programmatic changes such
as relocation or administration adjustments
For additional Title 22 Regulation information
http://www.dhcs.ca.gov/formsandpubs/laws/Pages/DHCS-14-006E-DMCProgramIntegrity.aspx
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ADDITIONAL INFORMATION
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Questions for this presentation will be collected and
responded to at a later date.
