Service Documentation Workshop

DHS AMH Division October 15, 2007

Service Service Documentation Documentation

WorkshopWorkshop

Presented as part of the Test Site Project for the

2004 Real Choice GrantIntegrating Long-Term Supports

with Affordable Housing


Terry N. Mastin, M.A.Housing Supports Reform SpecialistAddictions and Mental Health DivisionOregon Department of Human Services

[email protected]

Presented by:

mailto:[email protected]

DHS AMH Division October 15, 2007DHS AMH Division October 15, 2007

An OverviewAn Overview

• How are the services you provide to the people in the community paid for?

• What are the overall requirements for providing services?

• How can you document the services you provide correctly?


Section I

How are the services you provide to the people in the

community paid for?


MedicaidMedicaid•Title XIXTitle XIX of the Social Security Act is a of the Social Security Act is a Federal/State entitlement program that pays for Federal/State entitlement program that pays for medical assistance for certain individuals and medical assistance for certain individuals and families with low incomes and resources. families with low incomes and resources.

•Medicaid, became law in 1965 as a cooperative Medicaid, became law in 1965 as a cooperative venture jointly funded by the Federal and State venture jointly funded by the Federal and State governments to assist States in furnishing governments to assist States in furnishing medical assistance to eligible needy persons. medical assistance to eligible needy persons.

•Medicaid is the largest source of funding for Medicaid is the largest source of funding for medical and health-related services for America's medical and health-related services for America's poorest people.poorest people.


Within broad national guidelines established by Within broad national guidelines established by Federal statutes, regulations, and policies, each Federal statutes, regulations, and policies, each State:State:

(1) establishes its own eligibility standards (1) establishes its own eligibility standards (2) determines the type, amount, duration, and (2) determines the type, amount, duration, and scope of services scope of services (3) sets the rate of payment for services(3) sets the rate of payment for services(4) administers its own program(4) administers its own program

Medicaid


•Medicaid policies for eligibility, services, and payment are complex and vary considerably, even among States of similar size or geographic proximity.

•A person who is eligible for Medicaid in one State may not be eligible in another State.

•The services provided by one State may differ considerably in amount, duration, or scope from services provided in a similar or neighboring State.

Medicaid

(12/14/05). Medicaid Program General Summary. Retrieved August 22, 2007, from Centers for Medicare and Medicaid Services Web site: http://www.cms.hhs.gov/MedicaidGenInfo/03_TechnicalSummary.


Title XIX Social Security Act

Medicaid

Oregon Medicaid State Plan

Oregon Health Plan•Oregon Health Plan Standard•Oregon Health Plan Plus•Family Health Insurance Assistance Program (FHIAP)

Psychiatric Long Term Care•Extended Care Management Unit•Psychiatric Security Review Board

Mental Health Organizations

Community Mental Health Programs

Community Mental Health Provider


Consumers, Peers, Staff

MHOs, CMHPs, & Mental Health Providers

Oregon Health Plan and Psychiatric Long Term Care

Oregon State Medicaid Plan

Title XIX Medicaid

A Different View……………………..


Consumers, Peers, StaffMHOs, CMHPs, & Mental Health Provider Agencies,

Oregon Medicaid State Plan, OHP, PLTC

Medicaid, Title XIX

Another angle….


Section IISection II

What are the overall requirements for providing

services?


Medicaid Documentation

• Department of Human Services audits community providers through the Provider Audit Unit.

• Audits serve three functions: compliance, education, and technical assistance.

• Audits are required by Federal Statutes to assure and preserve the integrity of the Medicaid program.


Top 10 Mental Health Audit Findings

1. Lack of documentation, including annual updates:• Mental Health Assessment• Treatment Plan• Progress Notes for every service delivered• Signed Consent to Treat in file

2. Treatment Plan does not list frequency and duration of modalities to be delivered.

3. Progress note does not justify the therapeutic value of the treatment (named activity rather than therapy).

4. Progress note does not list the actual time spent.5. QMHA provided services outside the scope of practice.


Top 10 Mental Health Audit Findings

6. Excessive billing for H0034 (medication training and support).

7. Billing for services not provided and for units that exceed the time spent with the client.

8. Duplication of billing within the mental health staff9. Billing for services over the phone that are not

covered• Prescription refills• Confirming appointments

10. Lack of dates and signature on Treatment Plans, Assessments, and Progress Notes.

Fraud and Abuse Training, April 13, 2007, Eugene, OR.


Medicaid Documentation

DEPARTMENT OF HUMAN SERVICES, ADDICTIONS AND MENTAL HEALTH

DIVISION: MENTAL HEALTH SERVICES

OREGON ADMINISTRATIVE RULES

DIVISION 16 MEDICAID PAYMENT FOR

REHABILITATIVE MENTAL HEALTH SERVICES

Where to look for documentation requirements?


Supervision Requirements

• Medical supervision is documented through written agreement or job description between a Licensed Medical Practitioner (LMP) and the Provider and must occur annually including review of the Assessment and Treatment Plan

• Clinical supervision is documented through written agreement or job description and must occur monthly including oversight responsibility, monitoring and training


Medicaid Coverage: Documentation

ASSESSMENT

TREATMENT PLAN

PROGRESS NOTE


ASSESSMENT

TREATMENT PLAN

PROGRESS NOTE

Another view………….…


AssessmentAssessment

What are the minimum requirements for an assessment?


AssessmentAssessment

Done by QMHP during enrollment, and

Updated annually Reviewed and approved by LMP

at least annually DSM five axes diagnosis Clinical formulation


Assessment (cont.)Assessment (cont.) Includes treatment domains:

Cognitive

FamilySubstance AbuseEmotionalBehavioral DevelopmentalSocialPhysical health/medical careNutritionalSchool or VocationalCulturalLegal


Treatment PlanTreatment Plan

What are the minimum requirements for a Treatment Plan?


Treatment PlanTreatment Plan Specifies the DSM Axis I diagnosis

that is the medically appropriate reason for clinical care and the main focus of treatment.

Individualized treatment goals and measurable objectives to be achieved.

The regimen of rehabilitative mental health services that will be used to meet the treatment goals and achieve the measurable objectives.


Treatment Plan (cont.)Treatment Plan (cont.) The projected schedule for service delivery,

describing the expected amount, duration and scope of each type of planned therapeutic session or service.

The printed name, signature and date of signature of the primary QMHP.

The projected schedule for revising the Treatment Plan at least annually thereafter in conjunction with the annual Comprehensive Mental health Assessment.

Signature of consumer/client on plan. Criteria for discharge. LMP will approve the plan at least annually.


Progress NotesProgress Notes

What are the minimum requirements of a Progress Note?


Progress NoteProgress Note

The specific Medicaid service rendered.

The date the service was rendered. The printed or stamped name of the

QMHP or QMHA who rendered the service.

The setting in which the service was rendered.

The amount of time it took to deliver the service.


Progress Note (cont.)Progress Note (cont.)

The signature, computerized signature or written initials and date of this authentication and educational credentials of the QMHP or QMHA providing the service. If written initials are utilized to authenticate a progress note, the Provider must maintain a printed list of staff with their corresponding initials. A stamped signature may be utilized if the QMHP or QMHA also authenticates this signature by initialing and dating the stamped signature.


Progress Note (cont.)Progress Note (cont.)

For services that are not specifically included in the client’s Treatment Plan, or exceed the scope of the plan, maintain an explanation of how the services being billed relate to the Treatment Plan.


Section IIISection III

How can you document the services you provide correctly?


Putting it all together………

The assessment determines the “clinically appropriate” need for mental health services.

The treatment plan spells out the “medically appropriate” services to be delivered.

The progress note documents the delivery of the “prescribed services” and the “client’s clinical response to the specific treatment.”


ASSESSMENT

TREATMENT PLAN

PROGRESS NOTE

Remember?....................


Shifting the focus…………..YES—document the clinical intervention you provided.

YES—document the client’s/consumer’s response to the intervention.

YES—document the progress toward the goal the clinical intervention addressed.

NO—Narrate and/or describe what took place, blow by blow.


Variances

A variance from those requirements not established by federal regulations may be granted for up to one year bysubmitting a written request including:

Section of the ruleReasonAlternative practiceA timetable for compliance

to the AMH Medicaid Policy Unit


Document Packet

YCAMH Adult Behavioral Health YCAMH Adult Behavioral Health AssessmentAssessment

Sample Letter from a Collateral Sample Letter from a Collateral SourceSource

YCAMH Continued Service YCAMH Continued Service Request/Continuum of Care PlanRequest/Continuum of Care Plan

YCAMH Residential Services YCAMH Residential Services Treatment Plan AddendumTreatment Plan Addendum


What is a clinical formulation?What is a clinical formulation?

Break into small groups.Break into small groups.Example of clinical formulation in Example of clinical formulation in

packet.packet.Read “Sample Letter from a Collateral Read “Sample Letter from a Collateral

Source.” Source.” Come up with a clinical formulation, as Come up with a clinical formulation, as

a group, using that scenario.a group, using that scenario.


Treatment PlansTreatment Plans

Rejoin your small group.Rejoin your small group.Compare the minimum requirements Compare the minimum requirements

for a treatment plan to the YCAMH for a treatment plan to the YCAMH Continued Service Request/Continuum Continued Service Request/Continuum of Care Plan and the Residential of Care Plan and the Residential Services Treatment Plan Addendum.Services Treatment Plan Addendum.

What requirements are met?What requirements are met?Any required elements missing?Any required elements missing?


Progress NotesProgress Notes

As a large group, generate some As a large group, generate some scenarios on the services/supports scenarios on the services/supports you provide in a typical day.you provide in a typical day.

Provide a progress note for each Provide a progress note for each scenario that contains the minimum scenario that contains the minimum requirements for a progress note, per requirements for a progress note, per the Oregon Administrative Rules, the Oregon Administrative Rules, Division 16.Division 16.


Evaluation and Wrap UpEvaluation and Wrap Up

What was helpful, useful, and/or positive about the training today?

What was not helpful, not useful, and/or not positive about the training today?

What suggestions for improvement can you give me for future trainings.

Any other comments?

for attending today!

Documents

Service Documentation Workshop