WHY ???

1. Santa Barbara County Alcohol, Drug and Mental Health ServicesMedi-Cal Documentation TrainingJune 2009 Update

2. WHY ??? • Laws & Regulations • Ethical Responsibility • Best Clinical Practice • Money • Accurate documentation is the legal and ethical obligation of everyone who provides mental health services.

3. THE FIRST LAW

4. COMPLIANCE • IS EVERYBODY’S JOB • All staff are responsible for helping assure • that services and documentation • comply with legal and ethical standards. • - ADMHS Code of Conduct

5. If you are aware of any possible compliance violations, you must report them immediately. • You may report to your Supervisor, Quality Assurance, or the Compliance Helpline. • phone: 681-5113 fax 681-5117 • e-mail: jsleigh@co.santa-barbara.ca.us • Helpline (messages): 884-6855

6. Reports are confidential. • People who report are protected by State and Federal laws: Whistleblower Protections in the Federal False Claim Act: 31 USC Section 3730 (h) protects employees against discharge, demotion, suspension, threats, harassment, or discrimination by the employer because of lawful acts done by the employee in cooperating with the False Claims Act, including investigation for, initiation of, testimony for, or assistance in an action filed or to be filed under this section.

7. Medi-Cal Standards

8. The Basic Medi-Cal Rule • Medi-Cal only pays for • mental health interventions. • Every progress note must say what you did and must be related to mental health. • Document all services – but without a mental health intervention, code it “No-Bill”

9. Medi-Cal vs. “Whatever It Takes” • MHSA was set up to pay for services not covered by Medi-Cal • So… • Not everything built into our MHSA programs can be billed to Medi-Cal.

10. Examples: FSP & LOCRI • MHSA set up special forms that are required for some MHSA programs – ADMHS requires the LOCRI for adults in our clinics. • Unless something is added to those forms to make a billable service, • Filling out FSP & LOCRI = No-Bill service.

11. Excluded Diagnoses(can’t be listed as “Primary”) • Disorders due to a General Medical Condition • Substance-Related Disorders • Antisocial Personality Disorder • Cognitive Disorders (Delerium, Dementia, Amnesia) • Developmental Disorders • Autistic Disorder • Tic Disorders • Learning Disorders • Communication Disorders

12. How Much Time? • The time you claim must be the actual minutes spent delivering the service • Traveland documentationtime associated with a service can also be claimed • If you travel for more than 10 minutes, be sure to mention that in your note – don’t make the auditors guess!

13. Travel vs. Transportation • Travel means going somewhere so you can provide a billable service. Whether or not a client goes with you doesn’t matter. Travel is billable. • Transportation means taking a client somewhere so somebody else can provide a service. Transportationis not billable.

14. Therapeutic Behavioral Services • This is a special service, only for consumers under 21, with full-scope Medi-Cal, who: • Have serious emotional problems and serious behavior problems caused by a mental disorder • Need special 1-to-1 short-term support. • If you think a child or young adult needs TBS, contact the consumer’s Care Coordinator or the Manager or Team Supervisor of the nearest ADMHS Children’s Clinic.

15. CLIENT PLANS

16. Medi-Cal Rule #2 • Medi-Cal only pays for interventions that are part of a written, authorized, signed Client Plan.

17. The Client Plan / CSP • Legally required for all mental health providers. • Legally required to bill Medi-Cal or Medicare. • Provides informed consent for treatment. • Lets everyone know the goals of treatment and what services that will be provided.

18. Medi-Cal Requirements • No services except Crisis Intervention and Assessment can be billed without a diagnosis and treatment plan.* • A complete, formal Client Plan must be developed and signed within 60 days after services start.* • The formal plan must be updated every year. _____________________________________ * next page: what to do for 60 days!

19. But a formal plan takes time! • A Progress Note can authorize services for the first 60 days if it includes: • 5-Axis Diagnosis • Statement of Medical Necessity • Brief Description of Services • Clinician’s Gateway now has a template that meets all these requirements: • First Intake

20. Requirements: Formal Client Plan • The client or caregiver must participate in developing the plan. • The plan must be approved by • an LPHA or Psychiatrist* -and- • the client or legal guardian • Signatures on paper plans must include a DATE to be legal! * Medicare requires a psychiatrist

21. Adult Client Signature • There is NO planuntil it’s approved by the Client or Guardian. • Adult clients must either sign a paper copy of the plan or decline to sign. • “Declines” means that the client was offered a chance to sign, in a face-to-face meeting, and decided not to sign. • “Declines to sign” is as good as a signature and is valid for 12 months.

22. Children’s Parent/Guardian Signature • The parent or legal guardian can verbally participate in developing a plan and can verbally approve it. • The parent/guardian must sign (or refuse) the next time they are seen face-to-face. • Put the date of the verbal approval in the box for the parent/guardign signature.

23. Contents of the Plan • Goals – specific & observable & measurable • Proposed interventions to address the goals • Duration and frequency for interventions • Goals and interventions must be • consistent with the diagnosis

24. Goals • A goal is something that the client will achieve or acquire by participating in treatment. • There must be at least one goal for every impairment and every included diagnosis. • A goal must be something that can be observed and measured.

25. Measurable / Observable Goals • Client will decrease angry outbursts to a maximum of 2 per weekas reported by family. • Client willreport no more than 1panic attack per week. • Client will increase compliance with authority by attending school 5 days/week. • Client will increase functioning by complying with prescribed medications every dayas reported by residential staff.

26. Common Problem #1 • Client will take medications as prescribed. • Problem: No connection to mental health – not the way it’s written. • Solution 1:Client will manage psychiatric symptoms by taking meds as prescribed. • Solution 2:Client will prevent increase in impairments by taking meds as prescribed.

27. Common Problem #2 • Client will not use alcohol or other drugs. • Problem: No connection to mental health • Solution 1:Client will decrease hallucinations by abstaining from alcohol or other drugs per self report. • Solution 2:Client will improve participation in rehabilitation by reducing alcohol use to no more than 3 beers per day per self report.

28. Common Problem #3 • Client will maintain residence in the community. • Problem: No connection to mental health • Solution 1:Client will maintain residence in the community as part of recovery. • Solution 2:Client will maintain residence in the community by continuing to manage symptoms.

29. Interventions • An intervention is an action, activity, or service performed by another individual (usually a mental health provider). • A mental health intervention is an intervention related to a mental disorder.

30. Examples:Mental Health Interventions • provide therapy teach skills • evaluate symptoms • monitor progress help access services • educate family prescribe medications • gather information • review treatment plan • refer to physician

31. A Client Plan must have at least one mental health intervention for every goal. • Every intervention must have a frequency and duration – how often and for how long. • Basic examples: • Psychotherapy, 60 min per week, for 4 months • Med Support, 30 min per month, for 1 year • Individual Rehab, 30 min per day, for 6 weeks

32. New Audit Standard! • Every program that provides services must be listed in the Client Plan. • Every progress note billed to Medi-Cal must be related to the Client Plan.* • * Except emergencies, crises, decompensation

33. Progress Note Content • Must include: • The mental health intervention • A clear link to the client’s mental health condition or impairments • Should include: • Reason for the service • How the client looks and acts, and what the client says • Results of the service, or a plan

34. Progress Notes: “Do’s” • Write progress notes that stand on their own. • “Talked to Bob about client’s progress.” • You and your colleagues may know who “Bob” is – but other people don’t! • Write a progress note for every service activity, whether or not it is billable. • Write a progress note every time a client misses or cancels an appointment, and every time you miss or cancel.

35. Progress Notes: Dont’s” • (1) Don’t just copy and paste notes. • You can follow a basic outline and use basic language – but identical notes will not pass an audit • (2) Notes must justify the amount of time claimed • “Sent fax to pharmacy” doesn’t justify 45 minutes. Write down what else you did! • (3) Don’t make personal comments or judgments in progress notes – words like ugly, stupid, repulsive, sexy, and gorgeous aren’t professional

36. Warning: Other Client’s Names • NEVER name other clients in any note – violates HIPAA. • NEVER name any person if you say something about that person’s health – mental or physical - whether they are a client or not.

37. Group Notes: Negative Example • Generic note: “New member Abel Ayala joined group today. Reviewed group rules. Demetrius Drake talked about his girlfriend being pregnant and group discussed pregnancy and parenting.” • When Bob’s medical records are released, confidential information about the other group members is also released – without their authorization. • Don’t name other clients in any note!

38. Individual Notes: Negative Example • George’s mother Bernadette is taking medications to help with her anxiety. His brother Arnold is in treatment at Good Sam and is testing clean. His sister Edith, who he molested last year, is in treatment for PTSD. • That note includes Protected Health Information regarding 3 other people and gives information that identifies them. That is a serious violation of HIPAA.

39. Specific Procedures

40. These Services Can Be Reimbursed by Medi-Cal • Mental Health Services • Assessment • Evaluation and Plan Development • Therapy – Individual, Family, Group • Rehabilitation – Individual, Group • Collateral – Individual, Family, Group • Targeted Case Management • Crisis Intervention • Medication Support Services • Therapeutic Behavioral Services (TBS)

41. Procedures which can be provided by anyone, regardless of license: • Evaluation and Plan Development • Collateral – Individual or Group • Rehab – Individual, Family, or Group • Targeted Case Management • Crisis Intervention • TBS – licensed or under licensed supervision

42. Eval & Plan Development • EVAL: Gathering information about symptoms and functioning – only if it’s clearly related to PLAN DEVELOPMENT: • PLAN: Development or approval of plans, and monitoring client progress toward plan goals. • The formal, official Client Plan does not have to change – there can be changes in short-term interventions and activities.

43. A Major Medi-Cal “No-No” • “Narrative, descriptive notes” cannot be claimed – they must be coded “No Bill”. • To use a service code that bills Medi-Cal, a note must describe a mental health intervention – something you did. • Some of us were taught to write exactly this kind of note – but Medi-Cal says “NO BILL”

44. Narrative, Descriptive Notes • Example: Client neatly groomed, dressed in worn but clean suit. Movements, gait, posture stiff. Tangential speech at times. Denies hallucinations, delusions, SI, HI. Affect restricted, described mood as “worried” but unable to give details. Getting along with parents but he and brother still not speaking. RTC 1 week. • No intervention, code as “No Bill”

45. “Team” Meetings • The only people who can bill are people who are actively involved in providing treatment to the client. • The total amount of time billed can’t be more than 2 times the time the meeting lasted, plus documentation. • Each person who bills must document that they made an active intervention involving clinical decision-makingor clinical thought.

46. Example: Multi-Staff Eval/Plan • Reviewed client plan with team. Client will continue med management, substance abuse treatment, case coordination and individual therapy with focus on trauma. • Staff 1:I stated that individual therapy is necessary for continued progress. • Staff 2:This writer asked questions about the client’s substance abuse and how it relates to her PTSD.

47. Multi-Staff Eval/Plan • Some words that show an active intervention: • Said • Suggested • Asked • Discussed • Questioned • Proposed • Talked about

48. “Clinical Supervision” • If it looks like clinical supevision, it is clinical supervision – and that is a “No-Bill” service. • Consulting, talking with, reviewing cases with a person who is not providing direct treatment services to that individual client is clinical supervision.

49. Clinical Supervision - example • Reviewed case with Program Manager. Client is not responding well to therapeutic recreational activities. Will focus on art activities instead. • If the Program Manager is providing Assessment, Rehab, Therapy, or Collateral services to that client, this is Eval & Plan. • If the Program Manager isn’t providing direct treatment, this is TCM – No Bill.

50. Collateral • Services provided: • to (or with) a significant support person in the client’s life. • to help the client improve or maintain mental health status & achieve goals