3601 C Street Suite 878 Anchorage, AK 99503-5935 (907) 269-3608 Fax: (907)269-3623

1. State of AlaskaDepartment of Health & Social ServicesDivision of Behavioral HealthProgram Integrity Unit 3601 C Street Suite 878 Anchorage, AK 99503-5935 (907) 269-3608 Fax: (907)269-3623

2. An auditor quickly reviews your assessments • Do they document problems that really need treatment, and make TX recommendations? • Is there a multi-axial DX (that’s consistent)? • Is the client eligible for the services provided? • Are they conducted by qualified staff?

3. An auditor quickly reviews your treatment plans • Are goals directly related to problems in the assessments? • Are goals/objectives measurable and achievable? • Are TX plans overseen by a qualified staff?

4. An auditor carefully evaluates each progress notes • The center of an auditor’s attention • The final document that will determine if your agency must pay back money

5. What’s so important about Progress Notes?

6. Progress Notes • Document the active treatment by the clinician • Show that interventions were directed toward the goals/objectives of the plan • Contain clinically relevant information • Signed by qualified staff who provided the service

7. ACTIVE TREATMENT • (1) “ACTIVE TREATMENT" means the planning, delivery, and monitoring of a dynamic set of interrelated, effective, culturally appropriate, individualized mental health rehabilitation and related support services that: • (A) are designed to meet the mental health service needs of the recipient; • (B) use a specific and clear intervention strategy targeting behaviors identified in an intake assessment and individualized treatment plan;

8. ACTIVE TREATMENTCONTINUED • (C) are designed to improve functioning, reduce or eliminate negative symptoms, demonstrate ongoing measurable progress, and enhance the quality of the recipient's life; • (D) are provided by qualified staff to a recipient who is an active participant in the treatment process; and • (E) have a goal more specific than simply the avoidance of institutional care;

9. ACTIVE TREATMENT Is intended to improve the functioning and/or reduce the symptoms experienced by the recipient. Active treatment is designed and provided to move recipients toward recovery. Maintenance of current level of functioning or symptom control alone is not considered active treatment.

10. CLINICAL RELEVANCE • TO BE CONSIDERED CLINICALLY RELEVANT A PROGRESS NOTE MUST CONTAIN: • THE GOAL BEING ADDRESSED • THE ACTIVE STAFF INTERVENTION • THE RECIPIENT’S RESPONSE TO THE INTERVETRNION • THE RECIPIENT’S PROGRESS TOWARD THE GOAL

11. STAFFINTERVENTIONS • DESCRIBE WHAT STAFF DID DURING THE SESSION DESCRIBED IN THE PROGRESS NOTE. “THINK VERBS” • DISCUSSED, • CLARIFIED, • REVIEWED, • PROMPTED, • ENCOURAGED, • INSTRUCTED, • REDIRECTED

12. ADDITIONAL INFORMATION • PROGRESS NOTES MUST ALSO CONTAIN: • THE SERVICE PROVIDED • THE DATE THE SERVICE WAS PROVIDED • THE LENGTH OF TIME OF THE SERVICE • ANY OTHER CLINICALLY RELEVANT INFORMATION • THE SIGNATURE AND CREDENTIALS OF THE SERVICE PROVIDER

13. NO MAGIC WORDS • USE WORDS THAT DESCRIBE WHAT YOU ACTUALLY DID. • DO NOT THINK THAT YOU HAVE TO USE ANY “SPECIAL,” “MAGICAL” OR “CODE” WORDS TO WRITE A CLINICALLY RELEVANT NOTE. • THE ACTIVE STAFF INTERVENTION MUST BE AN ACTIVITY THAT FITS IN THE SERVICE CATEGORY THAT IS BEING UTILIZED.

14. John and I talked about how his drinking effects his life and tried to list the problems it has caused. He minimizes problems and is having trouble admitting just how much drinking has taken over his life. When he tried to argue that its not that much of a problem I asked how he got three DUIs and two other arrests related to drinking if its not a problem.

15. John and I talked about how his drinking effects his life and tried to list the problems it has caused. He minimizes problems and is having trouble admitting just how much drinking has taken over his life. When he tried to argue that its not really much of a problem I asked how he got three DUIs and two other arrests related to drinking if its not a problem.

16. Leroy came in on time for his appt. I went over his RET homework with him from last week. He’s having difficulty understanding the difference between a rational and irrational thought. I explained again what makes certain thoughts irrational and gave examples of a rational thought. When I confronted him about not trying very hard he admitted not being interested in working on this.

17. Leroy came in on time for his appt. I went over his RET homework with him from last week. He’s having difficulty understanding the difference between a rational and irrational thought. I explained again what makes certain thoughts irrational and gave examples of a rational thought. When I confronted him about not trying very hard he admitted not being interested in working on this.

18. Here’s what to do with progress notes to be in compliance and pass an audit

19. Progress Note do’s • Write the date you provided the service

20. Progress Note do’s • Write the date you provided the service • Write the service you performed (ie. indiv therapy)

21. Progress Note do’s • Write the date you provided the service • Write the service you performed (ie. indiv therapy) • Describe the interventions you used (active treatment)

22. Progress Note do’s • Write the date you provided the service • Write the service you performed (ie. indiv therapy) • Describe the interventions you used (active treatment) • Say what treatment goal(s) (from the plan) that you were working toward • Say something about how the client responded to your interventions

23. Progress Note do’s • Write the date you provided the service • Write the service you performed (ie. indiv therapy) • Describe the interventions you used (active treatment) • Say what treatment goal(s) (from the plan) that you were working toward • Say something about how the client responded to your interventions • Include any other clinically relevant information

24. Progress Note do’s • Write the date you provided the service • Write the service you performed (ie. indiv therapy) • Describe the interventions you used (active treatment) • Say what treatment goal(s) (from the plan) that you were working toward • Say something about how the client responded to your interventions • Include any other clinically relevant information • Indicate progress toward goal(s)

25. Progress Note do’s • Write the date you provided the service • Write the service you performed (ie. indiv therapy) • Describe the interventions you used (active treatment) • Say what treatment goal(s) (from the plan) that you were working toward • Say something about how the client responded to your interventions • Include any other clinically relevant information • Indicate progress toward goal(s) • Make sure you Sign and credential the note

26. Progress Note No-no’s • No “multiple day” notes • No “multiple service” notes • No “multiple staff” notes • No “undated” notes • No “unsigned” notes • No “observation only” notes • No “story” notes

27. ADDITIONAL THOUGHTS • MANY PROVIDERS HAVE INDICATED THAT EITHER THROUGH THEIR FORMAL EDUCATION, CLINICAL EXPERIENCE OR BOTH THEY HAVE BEEN TRAINED TO KEEP THEMSELVES OUT OF THE PROGRESS NOTE AND FOCUS ONLY ON THE CLIENT.

28. ADDITIONAL THOUGHTS CONTINUED • MEDICAID IS A MEDICAL INSURANCE PROGRAM THAT REIMBURSES FOR THE PROVISION OF SERVICES TO ELIGIBLE RECIPIENTS. • TO SUPPORT THE BILING FOR A SERVICE A SERVICE NOTE MUST SUPPORT THAT THE SERVICE THAT WAS BILLED AND PAID FOR WAS ACTUALLY PROVIDED. • NOTES THAT DO NOT CONTAIN INFORMATION ABOUT WHAT A PROVIDER DID DO NOT SUBSTANTIATE THE BILLING AND MAY BE SUBJECT TO REPAYMENT IN THE CASE OF AN AUDIT.

29. ADDITIONAL THOUGHTS CONTINUED (STILL) • SUPPORTING THAT THE SERVICE BILLED WAS ACTUALLY PROVIDED REQUIRES THAT STAFF PROVIDING A SERVICE INIDCATE WHAT THEY DID DURING THE COURSE OF PROVIDING THE TREATMENT SERVICE TO THE RECIPIENT.

30. Treatment Reviews • Treatment reviews evaluate and document progress toward each goal area from the tx plan • Include whether there are new MH problems during the review period • Includes a written summary of recommended changes to the tx plan • Review process is supervised by a MHPC as a minimum

31. That’s it Folks