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PRESENTS:

PRESENTS:. Early and Periodic Screening Diagnosis and Treatment (EPSDT) Chart Documentation Manual. 1. 1. 1. Please…. 2. Introductions and Logistics . CiMH Representative : Pam Hawkins CEUS Project Management Consultant: Lisa Scott-Lee. 3.

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PRESENTS:

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  1. PRESENTS: Early and Periodic Screening Diagnosis and Treatment (EPSDT) Chart Documentation Manual 1 1 1

  2. Please…. 2

  3. Introductions and Logistics CiMH Representative: Pam Hawkins CEUS Project Management Consultant: Lisa Scott-Lee 3

  4. Los Angeles County Department of Mental Health • Orange County Behavioral Health Services • Sacramento County Division of Mental Health • San Francisco County Community Behavioral Health Services • Adrienne Shilton, Senior Policy Analyst, California Council of Community Mental Health Agencies • Alex Agnieszka Medina, LCSW, Director of Quality Improvement, Child and Family Guidance Center • Carol Sakai, LCSW, Chief, Medi-Cal Oversight-South, State Department of Mental Health • David Cassell, LCSW, Mental Health QI Coordinator, Contra Costa Mental Health • Dean True, RN, Compliance Officer, Butte County Behavioral Health Services • Don Kingdon, PhD, Deputy Director, Small Counties Liaison, California Mental Health Directors Association • George Holbrook, MFT, Corporate Director of Quality Improvement and Compliance, Pacific Clinics • Julie Agojo, RN, Staff Mental Health Specialist, State Department of Mental Health • Kathy Seay, PhD, Consulting Psychologist, State Department of Mental Health • Katherine West, Executive Director, Seneca Center • Kim Suderman, LCSW, Deputy Director, San Joaquin County Behavioral Health • Maggie Roberts, ESQ , Associate Managing Attorney, Protection and Advocacy, Inc. • Nicette Short, MPA, Senior Policy Advocate, California Alliance of Child and Family Services • Norma A. Fritsche, RN, CNS, MPA, Mental Health Clinical Program Head, Standards & Quality Assurance, Los Angeles County Department of Mental Health • Pam Hawkins, Associate II, California Institute for Mental Health • Rita McCabe, LCSW, Chief of Medi-Cal Mental Health Policy Branch, State Department of Mental Health • Suzanne Tavano, BSN, PhD, Deputy Director of Mental Health, Contra Costa County Mental Health • Twylla Abrahamson, PhD, Program Manager, Quality Management Placer County Children’s System of Care • Uma Zykofsky, LCSW, Program Manager, Quality Management, Sacramento County Division of Mental Health A Collaborative effort by many. Acknowledgements 4 4 4 4

  5. USE OF THIS EPSDT CHART DOCUMENTATION MANUAL • This EPSDT chart documentation manual is presented to you by the California Institute for Mental Health (CiMH). This manual is to be used as a reference guide and is not a definitive single source of information regarding chart documentation requirements. • In all cases, the reader should defer to California Code of Regulations, Title 9, State and Federal regulations and Mental Health Plan (MHP) contractual requirements and applicable MHP policies and procedures. In addition, MHP’s may require additional standards and other requirements that are not covered in this manual. “The MHP has the authority to administrate and authorize services according to program and organizational need.” (Welfare & Institution Code 14680-14684). • Contact your MHP for information and guidance regarding use of this manual.   5 5 5 5

  6. DOCUMENTATION MANUAL USE • Quick Reference: neither comprehensive, nor definitive • Suggested Best Practice • Mental Health Plan Authority 6 6 6 6

  7. EPSDT Manual Organization • Seven Sections • Ten Appendices • Highlighted Boxes 7 7 7 7

  8. TOPICS COVERED IN MANUAL • Chapter One: Introduction • Historical Perspective • Freedom of Choice Waiver • Manual Use • Chapter Two: Planned Services • Mental Health Services • Medication Support Services • Day Treatment Intensive Services • Day Rehabilitation • Therapeutic Behavioral Services (TBS) 8 8 8 8

  9. Chapter Three: Unplanned Services • Crisis Intervention • Crisis Stabilization • Chapter Four: Targeted Case Management • Description • Site and Contact Requirements • Claiming • Lock-outs • Staffing 9 9 9 9

  10. Chapter Five: Reimbursement Requirements • Reimbursement Rules • Non-Reimbursable Services/Activities • Factors to Consider • Chapter Six: Documentation of Services • Overview • General Documentation Standards • Medical Necessity • Assessment • Client Plan • Progress Notes • Charts/Individual Records • Discharge Summary 10 10 10 10

  11. Chapter Seven: Staffing Qualifications and Approved Activities • Licensed Practitioner of the Healing Arts (LPHA) • License Waivered/Registered Professional • Graduate Students • Mental Health Rehabilitation Specialist (MHRS) • Other Staff 11 11 11 11

  12. Appendices • Sample Progress Notes • ICD-9 Included Diagnoses list for EPSDT • Reasons for Recoupment • Lock-out Crosswalk • Staffing Crosswalk • Local Contacts/DMH Letter and Information Notices/Resources • State Contacts/DMH Resources • Websites • Code References • Endnotes/Source Citation List 12 12 12 12

  13. INTRODUCTION • Chapter One: Historical Perspective • Short-Doyle Act • Realignment • Mental Health Programs • Managed Care • Early and Periodic Screening, Diagnosis and Treatment • Freedom of Choice Waiver 13 13 13 13

  14. PLANNED SERVICES (Pg 11) • Chapter Two: Mental Health Services • Individual or group therapy and intervention • Designed to reduce, restore, improve or maintain functioning consistent with goals 14 14 14 14

  15. TYPES OF MENTAL HEALTH SERVICES • Assessment • Plan Development • Therapy • Rehabilitation • Collateral 15 15 15 15

  16. MENTAL HEALTH SERVICE ACTIVITIES • Mental Health Services are included components of: • crisis residential treatment services, • crisis intervention, • crisis stabilization, • day rehabilitation, • and day treatment intensive. • Additional Mental Health Services • require prior MHP authorization • must be provided outside of Program hours • must be supported in the documentation 16 16 16 16

  17. MENTAL HEALTH SERVICE ACTIVITIES • Assessment (Pg. 12) • Evaluate current mental, emotional, or behavioral health. • Includes but is not limited to: • Mental Status • Clinical History • Relevant cultural issues • Diagnosis • Use of Testing Procedures 17 17 17 17

  18. MENTAL HEALTH SERVICE ACTIVITIES • Plan Development (Pg. 12) • Development of Client Plans • Approval of Client Plans • Monitoring and recording child’s progress as it relates to the Client Plan 18 18 18 18

  19. MENTAL HEALTH SERVICE ACTIVITIES • Therapy (Pg. 12) • A therapeutic intervention • Focus primarily on symptom reduction • Can be provided individually or a group • May include Family Therapy (child must be present) 19 19 19 19

  20. MENTAL HEALTH SERVICE ACTIVITIES • Rehabilitation (Pg. 12) • Improving • Maintaining • Restoring • Functional skills • Daily living skills • Social skills • Leisure skills • Grooming and Personal hygiene skills • Obtaining support resources and obtaining medication education 20 20 20 20

  21. REHABILITATION CAVEAT: DISTINCTION BETWEENREHABILITATION VS. PERSONAL CARE ACTIVITIES (Pg. 13) Rehabilitation Personal Care Services • Enable client to overcome limitations due to mental disorder • Example: Teaching client to prepare his/her meals, use utensil to eat meals • Performing activities for the client who are unable to do for themselves • Example: Feeding client, preparing client’s meals. 21 21 21 21

  22. MENTAL HEALTH SERVICE ACTIVITIES • Collateral (Pg. 13) • Services provided to Significant Support person as defined by California Code of Regulations, Title 9, §1810.246 • Consultation and Training support person • Family Counseling Focus is in achieving goals on youth’s Client Plan 22 22 22 22

  23. Significant Support Person defined(Pg. 14) "Significant support person" means persons, in the opinion of the child/youth or the person providing services, who have or could have a significant role in the successful outcome of treatment, including but not limited to the parents or legal guardian of the child/youth (who is a minor), the legal representative of the client who is not a minor, a person living in the same household as the child/youth and relatives of the child/youth. 23 23 23

  24. Contact and Site Requirements face-to-face or by telephone with the child or significant support person(s) provided anywhere in the community MENTAL HEALTH SERVICE Claims (Pg. 14) • Claiming Unit • Billing Unit is in minutes • No Cap or limit, however, in no case shall more than 60 minutes of time be reported or claims for any one person during a one-hour period • Staff cannot claim for non-treatment time. 24 24 24

  25. Contact Exception: Plan Development and Medication Support Services According to Title 9 CCR 1840.316(b)(4) Units of time may be billed regardless of whether there is a face-to-face or phone contact with the child/youth. NOTE: MHP may raise the bar regarding all contact requirements MENTAL HEALTH SERVICE Claims (Pg. 14) 25 25 25

  26. Prorated Requirement (Pg. 15): When claiming for Collateral or other Mental Health or Medication Support Service in a group setting, time claimed must be prorated for each child/youth represented. MENTAL HEALTH SERVICE Claims 26 26 26

  27. Prorated Example In a 30-minute, on-site, Medication Support Group of five parents representing 4 clients, the Psychiatrist explains the risks and benefits of different types of anti-depressant medication and potential side-effects, while the Nurse describes the signs and symptoms of depression. The charting time is twenty minutes. 30 minutes x 2 Med Support Providers + 20 minutes documentation time + 0 minutes Travel [on-site]) / Divided by the 4 represented clients In this example, Client claim is for 20 minutes As with any other group, time must be divided equally among the youth with open cases. The total time is multiplied by the number of staff, then it is divided by the identified clients with open cases. 27 27 27

  28. Medi-Cal versus Non-Medi-Cal Prorating If a Collateral or other group service is composed of both Medi-Cal and non-Medi-Cal eligible clients, the provider must determine if the rate for the service is the same between the two groups. If the rate is the same, the provider would prorate his/her time equally among the participants. However, if the rates are different, the provider must prorate each separately 28 28 28

  29. Mental Health Services Lockouts(Pg. 16) “Lockouts” are services that cannot be reimbursed or claimed due to the potential duplication of claim (“double billing”) or ineligible billing site. 29 29 29

  30. Mental Health Services Not Reimbursable: When provided by Day Rehabilitation or Day Treatment Intensive staff during the same time period that Day Rehabilitation or Day Treatment Intensive services are provided Mental Health Service Lockouts (Pg. 16) 30 30 30

  31. Mental Health Services Not Reimbursable: On days when Crisis Residential Treatment Services, Inpatient Psychiatric Services or Psychiatric Health Facility Services are reimbursed by Medi-Cal, except for the day of admission to the facility Mental Health Service Lockouts (Pg. 16 cont.) 31 31 31

  32. Mental Health Services Not Reimbursable: On days when the child/youth resided in a setting where the client was ineligible for FFP, e.g., Institute for Mental Disease (IMD), juvenile hall, Unless… There is evidence of post-adjudication for placement, (i.e., the court has ordered suitable placement in a group home or other setting other than a correctional setting, jail and other similar settings) Mental Health Service Lockouts (Pg. 16 cont.) 32 32 32

  33. Evidence of Post-Adjudication for Placement

  34. Mental Health Service Lockouts (Pg. 16 cont.) Because Crisis Stabilization is a package program, no other specialty mental health services are reimbursable during the same time period this service is reimbursed, except for Targeted Case Management. Can provide Mental Health Services before and after Crisis Stabilization Documentation should reflect services were provided outside of the Crisis Stabilization Program 34 34 34

  35. Exceptions to Mental Health Service Lockouts (Pg. 16 cont.) Therapeutic Behavioral Services (TBS) may be claimed during Day Rehabilitation and Day Treatment Intensive if TBS services were pre-authorized by the MHP and TBS must be delivered by staff other than the Day Rehabilitation and Day Treatment Intensive staff. 35 35 35

  36. Mental Health Service Staffing(Pg. 16) Consistent with scope of practice and as defined by State law, Mental Health Services may be provided by any person determined by the MHP to be qualified to provide the service 36 36 36

  37. Mental Health Co-Signature Requirements (Pg. 17) Determined according to the MHP’s internal quality management program and consistent with State law and within the scope and qualifications of the person providing the Mental Health Service. Note: Co-signatures can never be used to allow a person to provide a service that is beyond his/her scope of practice and/or qualifications. 37 37 37

  38. Planned Services Medication Support Services (Pg. 17) Services include: prescribing, administering, dispensing and monitoring of psychiatric medications or biologicals that are necessary to alleviate the symptoms of mental illness 38 38 38

  39. Medication Support Services(Pg. 17) Evaluation of the need for medication; Evaluation of clinical effectiveness and side effects; Obtaining informed consent; Medication Education Instruction in the use, risks and benefits of and alternatives for medication; Collateral and plan development related to the delivery of the service and/or assessment of the child; and Prescribing, administering, dispensing and monitoring of psychiatric medications or biologicals. Service Activities may include, but are not limited to: 39 39 39

  40. Medication Services neither Claimable nor the Responsibilityof the MHP under EPSDT (Pg. 17) Prescribed (non-mental health) drugs as described in Title 22, Section 51313, and laboratory, radiological, and radioisotope services as described in Title 22, Section 51311, except when provided as hospital-based ancillary services Physician services as described in Title 22, Section 51305, that are not psychiatric services as defined in Section 1810.240, even if the services are provided to treat a diagnosis included in Sections 1820.205 or 1830.205 40 40 40

  41. Medication Support Services(Pg. 17) Contact and Site Requirements Medication Support Services may be either face-to-face or by telephone with the youth (if age 18 to 21) or with significant support person(s) May be provided anywhere in the community • Claiming Unit • Billing Unit is in minutes • Medication Support Services that are provided within a residential or day program must be claimed as Medication Support Services separately from the residential or day program service 41 41 41

  42. Medication Support Service Maximum Reimbursement (Pg. 17) The maximum amount reimbursable for Medication Support Services in a 24-hour period is: 4 hours (240 minutes) 42 42 42

  43. Medication Support Services during Residential or Day Program Service(Pg. 18) NOT a lock-out during Day Rehabilitation and Day Treatment Intensive hours of operation HOWEVER: Medication Support Service should not exceed the amount of time required for the 50% attendance of the day program Child/Youth must still attend a minimum of 50% of the DR or DTI program to claim both DR/DTI and Med Support Service concurrently 43 43 43

  44. Medication Support Services Staffing (Pg. 18) Medication Support Services must be provided within the scope of practice by: Physician Registered Nurse Licensed Vocational Nurse Psychiatric Technician Pharmacist Physician Assistant 44 44 44

  45. Medication Support Service Documentation (Pg. 18) Supports the need for medication; evaluation of clinical effectiveness and side effects; obtaining of informed consent; instruction in the use, risks and benefits of and alternatives for medication; and collateral and plan development related to the delivery of the Medication Support Service 45 45 45

  46. Medication Support Services: Annual Assessments & Client Plans(Pg. 18) Documentation must support continued medical necessity for Medication Support and limited case management services. Like any other Client Plan, client/caregiver involvement and participation must be documented 46 46 46

  47. Planned Services Day Treatment Intensive Services (DTI) [Pg. 19] a structured, multi-disciplinary program of therapy may be an alternative to hospitalization, avoid placement in a more restrictive setting, or maintain the child in a community setting, which provides services to a distinct group of beneficiaries. Services are available at least 3 hours and less than 24 hours each day the program is open. Service activities may include, but are not limited to, assessment, plan development, therapy, rehabilitation and collateral 47 47 47

  48. Half day and Full Day DTI Programming(Pg. 19) Half-day shall be billed for each day in which the child/youth receives face-to-face services in a program with services available four hours or less per day. Services must be available a minimum of three hours each day the program is open. Full-day shall be billed for each day in which the child/youth receives face-to-face services in a program with services available more than four hours per day. 48 48 48

  49. Half day and Full Day DTI Programming (Pg. 19) Half-dayshall be billed for each day in which the child/youth receives face-to-face services available four hours or less per day. available a minimum of three hours each day the program is open. Full-dayshall be billed for each day in which the child/youth receives face-to-face services available more than four hours per day. 49 49 49

  50. DTI Required Service Components(Pg. 19) Daily community/milieu meeting, A therapeutic milieu, Contact with significant support person(s) Skill-building groups, adjunctive therapy, and psychotherapy May include process groups in addition to psychotherapy. Programs must have established protocol for responding to a child/youth’s mental health crisis 50 50 50

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