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Children’s Documentation &
Performance Outcomes TrainingPart I
Presented By
Quality Management
01-02-2011 1
Training Outline • Introduction to the Mental Health Plan
• Clinical Documentation Overview
• Clinical Assessment Package
• Progress Notes and Service Codes
• Billable versus Non-Billable
• Resources and Contact Information
2
Training Goals
• Review documentation standards and timelines for completion of clinical documentation
• Review Medi-Cal requirements for Assessment, Client Plan, and Progress Notes
• Answer questions and provide technical assistance
3
Sacramento County Mental Health Plan
• County Vision / Mission / Principles
• Target Populations / Medical Necessity
• Commitment to Cultural Competence
• Language Requirements / Interpreting Services
1 4
Medical Necessity and Target Population
Criteria that define service need based on inclusion of specific signs, symptoms, and conditions, as well as proposed mental health treatment
Sacramento County Target Population (Youth):- MediCal
- Chapter 26.5 (AB3632)
- Healthy Families
- Uninsured Youth
5
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
2-2A 6
Medical Necessity (Cont’d)
When recording a client’s problem, the clinician must document:
• Onset
• Frequency
• Duration
• Severity of Symptoms
• Resulting Functional Impairments
7
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.
8
Service Necessity
Service Necessity includes 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.
9
3632/26.5 Guidelines
• Child/youth must have significant mental health condition interfering with ability to benefit from his/her education
• Caregiver’s request for an IEP initiates process for obtaining services
• Child/youth must qualify for special education and require more than short-term counseling.
3 – 5, 4A 10
3632/26.5 Guidelines
• Children’s Case Management Services (CCMS) conducts a comprehensive assessment to determine eligibility
• Provider must coordinate delivery of mental health services with CCMS
• Treatment plan must include one mental health goal that targets education
11
3632/26.5 Guidelines
• All mental health services provided are pursuant to the IEP. An IEP is required for any changes in level of care and discontinuation of mental health services
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.
12
Cultural Competency
• Making Cultural Accommodations
•
• Using Interpreters
Web Address: http://www.sacdhhs.com/article.asp?contentD=482
Documenting Accommodations
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
Threshold LanguagesA “Threshold Language” is defined as a primary language other than English spoken by 3,000 Medi-Cal beneficiaries or 5% of the population, whichever is lower in an identified geographic area.
• Sacramento is second to Los Angeles in number of beneficiaries who speak a “Threshold Language.”
15
Sacramento CountyThreshold Languages
Sacramento County has FIVE Threshold Languages:
�Spanish
�Russian
�Hmong
�Vietnamese
�Chinese (Cantonese)
16
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.
17
Culture and Services
• Recognize possible links between culture and life experiences such as trauma and discrimination
• Review literature, seek consultation, and be willing to learn about your client’s culture.
18
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
19
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)
20
Clinical Documentation
• Client Data Sheet (CDS)
• Assessment Client Plan (ACP)
• Re-Assessment & Re-Authorization (R&R) Use Forms with AVATAR logo
• Child/Youth Health Questionnaire & Update (CHQ)
• Progress Notes
• Discharge Re-Assessment Summary
• Annual Medication Service Plan (if app.)
21
The Basics of Clinical Documentation
6, 722
Consents and Releases
• Obtain legal guardian consent to treat for all minors as required by law.
• HIPAA compliant Authorizations to Obtain or Release Health Records are required.
• A current medication consent is required for each medication the client is taking.
8, 8A, 8B, 9, 9A 23
Working Definitions• Authorization Period: Generated in AVATAR by
Access Team.
• Provider Start Date: First billable service to AVATAR; face-to-face contact required, with limited exceptions
• Paperwork Cycle: Begins at the provider start date through the end of the authorization period.
• Staff Classifications
– LPHA - MD,PhD, RN, LCSW, MFT, Waivered Staff (ASW or IMF) and Graduate Student
– MHRS - Degree & Experience
– MHA-I, MHA-II and MHA-III- Experience and Education beyond High School 24
Service Authorization • All services must be authorized by the Child
and Family Access Team.
• Client record must include AVATAR authorization print-out (Detailed Authorization).
• All Services must be delivered within the authorization period for reimbursement.
• Requests for reauthorization must be submitted at the same time when multiple providers are open simultaneously.
10 25
Service Request Form
All services go through the
Child and Family Access Team
Phone: 875-9980
Fax: 875-9970
26
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
11 27
A Complete Clinical Assessment Packet Consists of:
• Client Data Sheet (CDS)
• Assessment Client Plan (ACP)
• Child Health Questionnaire (CHQ)
28
Paperwork Cycle SampleAuthorization
Period Provider
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
29
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.
30
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
31
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.
32
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.
33
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
A 34
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
35
Client Data Sheet(CDS)
36
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
37
Assessment Client Plan (ACP)
Sample ACP-12, 13
38
ACP Overview
1. Reasons for services includes current symptoms, behaviors, and level of functioning to support Medical Necessity.
2. Identify risks to client or others and follow-up with a safety plan in summary section of ACP, page 6.
Page 1 of ACP
39
ACP Overview
3. Psychosocial History includes living situation, daily activities, social support, family involvement, …and cultural experiences such as acculturation, language, discrimination, etc.
4. Mental Health History includes onset, stressors, and treatment response to previous mental health services.
Page 2, 3 of ACP 40
ACP Overview
5. Substance Use: Consider a secondary diagnosis of Substance Abuse or Dependence as appropriate
– Include a secondary substance abuse goal if appropriate; the mental health goal is always primary.
Page 3 of ACP
41
ACP Overview
6. Current Psychiatric Medications includes medication name, dosages, physician name and prescription dates
7. Community Functioning Outcomes includes living arrangements, school, legal issues, and medical care
8. Mental Status Exam
Page 4, 5 of ACP 42
ACP Overview
9. Five Axes Diagnosis from DSM-IV TR and corresponding ICD-9 Code for the Primary Axis I diagnosis. LPHA is the Diagnosis Source, not the DSM-IV.
10. Summary/Additional Comments/ Continuation: Include Safety Plans in this section
Page 6 of ACP 43
ACP Overview (last page)
10. Tentative Discharge Plan 11. Coordination of Care (contact information)12. Client (10 yrs-older) and caregiver signatures
are required to document participation; if no signature, document reason using space on form
13. Provider signature required within 60 days, including co-signature, if required
Page 8 of ACP
44
Member Handbook & Problem Resolution Guide
• Provide and review Member Handbook and Problem Resolution Guide to client and caregiver at start of service
• 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
45
Comprehensive 0-5 ACP
• The 0-5 ACP is used for children from birth to the child’s fifth birthday
• The 0-5 ACP includes questions to meet 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
46
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).
47
ACP for 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.
48
TREATMENT PLANNING
49
Life Goals vs. Treatment Goals
• Life Goals are actual quotes or statements indicating the youth’s hopes, dreams or ambitions that 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 the youth’s mental health condition.
50
Treatment Goal Requirements • Specific and Measurable • Type of Intervention • Child/Youth/Family Strengths and Challenges • Document responsibilities, stating 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
51
Treatment Goal Selection• Address mental health symptoms,
behaviors, and level of functioning • Collaborate with client and caregiver • Consider Culture • Clients receiving 26.5 services require one
education related goal • Substance Use goal if appropriate and
always follows mental health goal 14
52
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.
53
Signature Requirements• Obtain provider signature, including co-
signature if required, within the 60-day timeframe
• If no signature(s) obtained, document reason on form and continue to document efforts to obtain signature
• Client/Caregiver must participate in plan development and signatures on plan document participation
54
Changing a Diagnosis 1. Document the change in a progress note
and include justification, date, and name of staff who changed the diagnosis.
• Only an LPHA may change a diagnosis.
2. Document the change in designated section on the ACP next to original diagnosis.
3. Update the Client Data Sheet and AVATAR Include diagnosis source and date of
change 55
Change of Coordinator• Document change of Coordinator, including
date of change and reason in progress note
• Write name of new Service Coordinator in the Coordinator’s Name Change section on the current ACP or R&R and remember to include the date of the change
• Update the Client Data Sheet (CDS) and AVATAR to reflect the change
56
Clinical Vignette
15
57
Re-Authorization & Re-Assessment
(R&R)
Request for Continuation of
Services from Access
16 58
Essential R&R Elements: • Current Medical Necessity • Current Level of Functioning • Current Need for Services • Identify Updates/Changes from ACP • Identify goals continued from
previous plan (progress notes should document progress made)
• Collaborate with Client/Caregiver on modifications/changes to plan
Submit to Access 15 days prior to the authorization expiration
59
Glossary
• The glossary is organized to correspond with the reading order of the ACP/R&R.
• The MSE and Substance Abuse sections of the ACP/R&R are explained in more detail.
17 60
Child Health Questionnaire (CHQ)
Linking Physical Health and Mental Health
61
Important CHQ Elements
• Required with ACP and CDS within 60 Days of Provider Start Date
• Medications, dosages, dates of initial prescriptions & refills
• Allergies and adverse reactions or lack of allergies/sensitivities
• Pre-natal and perinatal events, and complete development history
62
Important CHQ Elements
• Document reason in progress note for items left blank or marked “unknown”
• Progress note required when linking client to a physician or healthcare provider
• Use the CHQ Update to record healthcare updates annually and upon transfer
63
PROGRESS NOTESOVERVIEW
64
Progress Note Elements• Key topics discussed in the session • Current symptoms and behaviors,
including clinical findings and interpretations
• Accommodate language and explore culture and ethnicity
• Describe how interventions are addressing the client’s mental health condition
65
Progress Note Elements (Cont’d)• Note should document 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. 66
Clinical Introductory Note
Written at first visit, or very soon thereafter, summarizing the client’s mental health condition and service needs. The note includes, but is not limited to:
• Client identity, including age, gender, ethnicity, etc.• Referral source • Cultural accommodations • Presenting condition, including symptoms,
behaviors, and level of functioning • Need for service and Medical Necessity support • Client strengths, supports, and challenges • Plan for services 18
67
Service Codes• See Service Code Definitions/Training
Guide for master list of codes, definitions, and progress note examples
• Providers are responsible for accurately entering services into Avatar, in accordance with contractually specified services and codes
• Consult your supervisor, Quality Management and/or contract monitor for clarification
19-19.1,19.2 68
69
Types of Progress Notes
• Collateral
• Assessment
• Individual Therapy
• Group Therapy
• Group Session
• Rehabilitation
• Plan Development
• Therapeutic Behavioral Services
• Medication Support
• Case Management Brokerage
• Crisis Intervention
• Cancellations
• No Shows
19A
AVATAR Service Codes 5/27/2009 (Note: Lockout Codes)
Collateral 95010
• Service to a significant support person for 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. 70
Sample Collateral NoteReturned call to caregiver. Talked to father about a recent incident at the school resulting in the client’s 3 day suspension. Mother reports that client started a fight with another boy in his classroom. Mother is very concerned about client’s behavior and the impact on other children in the family. Discussed safety issues in the home and reviewed interventions practiced in sessions to help de-escalate client’s aggressive behaviors. Will meet at our regular time next week.
- Jerry Ruiz, LCSW 71
Assessment Code 93010
• Evaluate current status of behavioral health and level of functioning
• Assess for medical necessity; includes/not limited to mental status exam, clinical and diagnostic history, etc.
• Accommodate for language and culture
• Used to complete ACP and R&R and supports development of the client plan
• Use of Testing Procedures
72
Sample Assessment NoteMet with client and Father for first appointment. Client and Father are bi-lingual, prefer services in Hmong, and this bi-lingual writer accomodates preference. Client is a 12 y.o. Hmong male referred by school personnel due to truancy, poor academic performance and aggressive behavior. He is the middle of 4 children. Mother killed in auto accident 2 years ago; Father struggles to care for children. Client denies any gang affiliation, however reports occasional alcohol and marijuana use. Explained how services will be provided, problem resolution, confidentiality, etc…Plan: Continue Assessment at appointment… – Christopher Thao, MFT 73
Individual Therapy 97010
• Psychotherapeutic intervention to improve symptoms, increase level of functioning, and support developmental progress
• Guided by the treatment plan
• Only an LPHA, or a graduate student trainee under the supervision of an LPHA, may provide individual therapy
74
Sample Individual Therapy NoteMet with client for individual session and reviewed progress toward treatment goals. Client reports feeling more comfortable in social situations, evidenced by increased socialization with peers joining the school track team. Client displays calm demeanor with minimal foot tapping and no sign of facial tension. We discuss client’s use of coping strategies that are helping her feel less anxious in social situations. Role played some additional coping strategies and praised client for her active participation in and out of session. Plan: Meet next week… - Leslie Bly, MFT
75
Group Therapy vs. Group Session
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
76
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.
77
Group Progress NotesA 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)
78
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. -Juliana Garza, MHRS
2079
Discussion of AVATAR Group Note
Screen fields for discussion Service Type: 1-Mental Health Svc Service Code: 96520 Practitioner Name and Staff ID Time: 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
80
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 next Wednesday, 2pm. Joe Therapist, MHRS
21 81
Discussion of AVATAR Note
Screen fields for discussion: Service Type: 1-Mental Health Svc Service Code: 96520 Practitioner Name and Staff ID Time: Service=120, Doc=30, Travel=30,
Total=180 Co-Practitioner Name and ID Time: Service=120, Doc=20, Travel=0, Total=140 EBP/SS(1), etc. Number of Clients: 5
21-Back82
Rehabilitation 94000
• Services that assist a client to improve, restore or maintain: – 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 83
Sample Rehabilitation NoteMet with the client at new apartment to assist with independent living skills and transition to living alone. Worked on budgeting and helped client develop reminder list of monthly tasks and deadlines for paying bills, scheduling doctor appointments, and other responsibilities. Guided client in creating phone list with emergency numbers and important contacts. Plan: writer will call client later this week and will make follow-up visit in one week.
- Carrie Lee, MHAII
84
Plan Development 98500 • Service activity involving development
and implementation of a plan or intervention
• The progress note must clearly document steps for a planned intervention and follow-up
• Plan development is not reimbursable for 3632 only clients; bill to Assessment for treatment planning
85
Sample Plan Development NoteMet with client and caregiver to develop a treatment plan to help client reduce aggressive, acting out behaviors that include initiating school fights and self harm behaviors. Discussed goals and objectives related to appropriate expression of anger, reduction in aggressive threats and actions, and reduction in self-harm behavior. Received input from client and caregiver. Also developed a safety plan with crisis numbers and alternative behaviors to practice when client begins to feel agitated. Plan to provide family therapy weekly. Stacy Williams, LCSW
86
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
87
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 psychiatric hospitalization within 24 months Being considered for placement in a group home/ RCL 12 or higher Previously received TBS while a certified class member
88
Medication Support97500 / 97510 / 98010
• Only MDs, RNs, LVNs, and PTs can bill these services.
89
90
Case Management/Brokerage 94510
When to Bill Case Management Brokerage?
Linkage to:- Primary Healthcare Services-Other Mental Health Services-Non Mental Health Services
• Co-staffing for inter/intra agency purposes must be non-supervisory, non-duplicative, with meaningful planning and implementation
• Specific to discharge placement planning within 30 days of psychiatric hospital discharge
22, 22A 91
Sample Case Management Note
Writer attended school meeting with teacher, school psychologist, and client’s mother. Discussed progress and reviewed action plan from last meeting. Client has reduced incidents of disrupting class and interrupting class activities. Agreed to stay in contact to monitor progress and coordinate services. Writer shared that I am considering closing case if progress is maintained for next 30 days.
-Carl Johnson, MFT 92
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”.
93
Elements of Targeted Case Management Progress Note 9Projective date of Discharge 9Consultation and participation on discharge
plan as relating to placement needs of client 9Monitoring and Follow up Activities regarding
transitioning from inpatient to discharge 9Dates, Staff Signatures and Client Service
Information (CSI) data information
Bill to 94510 23 94
95
Crisis Intervention 95510
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
96
More Crisis Billing
• Services are typically face-to-face with client, however may also be by telephone with client orsignificant support person
• Services may be provided anywhere in the community
• May require multiple service activities, under the umbrella of crisis to bring the situation toresolution
• Crisis billing must stop once the crisis is resolved, however it may be appropriate to billanother service activity if continued services areprovided
97
Sample Crisis Intervention NoteMother phoned to inform writer that she found a bottle of Tylenol next to a half written suicide note. Client has been in treatment for depression and relationship withboyfriend ended last week. Client is currently in her bedroom crying. Mother removed pills and will call 911if situation escalates. Worker immediately travels to the home to assess/intervene. Client began sharing herfeelings of distress…states she wanted her boyfriend to“listen to me” and really didn’t want to kill herself. Crisis de-escalated, safety plan put in place; daily phonecheck-in sessions to start and increased individual sessions; Appointment scheduled next week, June 8th, for individual therapy. Dottie Kincaid, LCSW
98
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.
99
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 received voice mail message from client’s mother today, stating that she moved to Oregon with her children to be closer to her family for support. Case will be closed. As previously documented, client demonstrated progress toward treatment goals with improved grades and follow through on chores at home and no truancy for 3 mos.. Stacy Williams, LCSW
100
Discharge Re-Assessment Summary Billed to Individual Therapy
Met with client for final therapy session.Discussed progress made toward treatmentgoals and strategies for maintaining progress.Client demonstrates increased capacity, by selfand teacher report, to pay attention in class andfollow through to finish school work andchores. Client continues to find it difficult to remain seated, saying he often feels “driven by amotor,” and wait his turn, however has shown improvement per teacher report. Client states he wants to “keep up the good work,”… Dottie Kincaid, LCSW
101
Progress Note Sample #1
Worked on ACP. Plan: Schedule session to complete ACP.
-Sandy Claus, LCSW
How would you bill this?
102
Progress Note Sample #2Discussion with psychologist regarding results of psychological testing and confirmation of ADHD and Reading Disorder. Obtained information helpful to upcoming IEP meeting and treatment planning. Based on information obtained, this clinician will discuss behavioral management options with client’s teacher and parents. Plan: Schedule treatment planning session with client and parents. -Matilda Smith, ASW How would you bill this?
103
Progress Note Sample #3
Spoke with client’s father regarding client’s behavior at last nights family outing. Father made observation that client tests limits with him but not with Mother. Clinician and writer discussed lack of follow through by father with consequences after limit testing Encouraged father to continue setting limits that he can enforce…..
-Elliott Johnson, LCSW
How would you bill this? 104
Progress Note Sample #4
Traveled to client’s home for scheduled appointment and there was no response to knocks; returned to office and reviewed client’s chart
-Sandy Jones, LMFT
How would you bill this?
105
Progress Note Sample #5
Telephoned client’s caregiver to reschedule appointment…
-Alan Jones MHA III
How would you bill this?
106
Document non-reimbursable services but do not bill.
Examples:
• No Shows
• Supervision
• Transportation
• Administrative Activity
107
No-Shows and Cancellations are not billable, however…
Billing is allowed if a reimbursable mental health service was provided
in relation to the
No-Show/Cancellation
108
Supervision – non-billable
vs.Consultation – billable
• Supervision: Time providing supervision to staff/students for the purpose of: – Obtaining BBS required clinical hours, and/or – Monitoring/managing 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.
109
110
Transportation – non-billable
vs. Travel Time – 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.
Administrative ActivitiesNon-Billable
• Filing • Faxing • Scheduling an Appointment • Leaving/Retrieving a Message • Reserving and setting up a room or
audio/visual equipment for the session • Studying or researching a topic
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Other Non-Billables• Billing for second staff when the roles appear
duplicative, non-essential, or inappropriate for the individual service or group.
• Excessive billing for chart review with no documented product such as updated plan, or concrete outcome resulting from the review.
• Providing mental health services to someone other than the beneficiary
• Providing interpretation services • Non-Mental Health Services • Billing during a Lock-Out Situation
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Annual Medication Service Plans AMSP
