CALIFORNIA CODE OF REGULATIONS TITLE 22 Drug Medi-Cal Patient Record Requirements

1. CALIFORNIA CODE OF REGULATIONS TITLE 22 Drug Medi-Cal Patient Record Requirements

2. TITLE 22 SECTIONS • Section 51341.1 • Section 51490.1 • Section 51516.1

3. PSPP UTILIZATION REVIEW • No Advance Notice • List of records to be reviewed • Medical Directors License Number • Counselor certification/NPI • Physical inspection of the facility • Report and Corrective Action Plan • Recovery of Funds – Technical Assistance Section 51341.1 (m)

4. PROVIDER RESPONSIBILITIES • Establish and maintain an individual patient record • Keep group counseling sign-in sheets which must include the date and duration of the counseling session, as well as the beneficiary’s signature • Provide services Section 51341.1 (g)

5. WARNING!! It is your responsibility to follow the regulations – • what you heard • what the last reviewer said • what you did at your last program That’s nice, but what do the regulations say? If you need an interpretation, get it in WRITING Use our e-mail or send a letter!

6. E-mail questions to: DMCanswers@adp.ca.gov See our website for additional information: adp.ca.gov _

7. Thou Shall Not: 1. Sign any patients name to any document or sign-in sheet. 2. Sign any document using the Medical Director’s, or any one else’s, signature. 3. Intentionally, submit erroneous billings. 4. Falsify any MediCal record/document. 5. Back Date/Forward Date any signature. ` Report any suspected questionable billing to the proper Authorities Department of Health Services MediCal Fraud Hotline.: (800)822-6222 Department of Justice MediCal Fraud Hotline: (800)722-0432

8. THE TREATMENT PROCESS • Intake (admission and assessment) • Treatment Planning • Treatment services and referrals • Justification for continuing services • Discharge

9. MEDICAL NECESSITY • Medical necessity is THE critical issue in the provision of Drug Medi-Cal substance abuse services. • Services must “be prescribed by a physician”, and “provided by or under the direction of a physician”. [51341.1(a) & (h)] • Medical necessity documents provide verification that these requirements have been met.

10. MEDICAL NECESSITY (Cont’d) • the physician’s admission of each beneficiary pursuant to Subsection (h)(1) of this regulation,” • Physical Examination/Wavier • The physician’s signature on the initial and subsequent treatment plans. • Assignment of AOD DSM code. • The physician’s signature on 6 month justification to continue treatment services document.

11. Definition: ADMISSION TO TREATMENT DATE • The date of the first face-to-face treatment service. Section 51341.1 (b)(1)

12. ADMISSION The provider must develop and use criteria and procedures for admission. This must include the beneficiary’s: • Personal history • Medical history • Substance abuse history (lifetime) Title 22, 51341.1(h)(1)(A)(ii)

13. ADMISSION The provider must develop and use criteria and procedures for admission. The definition of “Intake” in Subsection (b)(10) lists specific steps that must be completed in the admission process:

14. ADMISSION (Cont’d) • The evaluation or analysis of the cause or nature of mental, emotional, psychological, behavioral and substance abuse disorders • The diagnosis of substance abuse disorders utilizing the DSM • The assessment of treatment needs to provide medically necessary treatment services. Title 22, 51341.1(b)(10)

15. The Treatment Standards require, at minimum, assessment of treatment needs in the following areas: • Education • Vocational counseling and training • Job referral and placement • Legal services • Medical and Dental services • Social/recreational services • Counseling services

16. TITLE 22 ADMISSION REQUIREMENTS • Complete an assessment of the physical condition of the beneficiary within 30 calendar days of the admission to treatment date, by either a • Physical exam, or • Waiver of the admission physical exam Title 22, Section 51341.1 (h)(1)(A)(iii)

17. ADMISSION (Cont’d) • Admission physical exam – “A physical examination of the beneficiary by a physician, registered nurse practitioner, or physician assistant authorized by state law to perform the prescribed procedures.” • The physical exam document (or a copy) must be located in the patient record. Title 22, Section 51341.1 (h)(1)(A)(iii)(a)

18. ADMISSION (Cont’d) • The waiver must explicitly waive the admission physical exam, and must state a basis for the waiver. • Preferred language: “Based on my review of the beneficiary’s medical history, substance abuse history and/or most recent physical exam, I waive the admission physical exam.”

19. ADMISSION (Cont’d) The entire admission process establishes initial medical necessity. As a result, any incorrect or missing information means that medical necessity has not been established and all claims for services for that treatment episode will be disallowed.

20. TREATMENT PLANNING (Cont’d) The initial treatment plan must be: • Individualized • Based on the information obtained during the intake and assessment process. Section 51341.1 (h)(2)

21. TREATMENT PLANNING (Cont’d) It must include the following 6 elements: • A statement of the problems to be addressed • Goals to be reached which address each problem • Action steps which will be taken by the provider, and/or beneficiary to accomplish identified goals Section 51341.1 (h)(2)(A)(i)

22. TREATMENT PLANNING (Cont’d) • Target dates for the accomplishment of actions steps and goals • The assignment of a primary counselor • A description of the services, including the type of counseling, to be provided and the frequency thereof. Group counseling must be a specific number of sessions per unit of time – individuals can be “as needed”, but must be on the treatment plan. Section 51341.1 (h)(2)(A)(i)

23. TREATMENT PLAN TIMELINES • The initial treatment plan must be completed by the counselor within 30 calendar days of the admission to treatment date. • The physician must review, approve and sign within 15 calendar days of the signature by the counselor. Section 51341.1(h)(2)(A)(ii)

24. TREATMENT PLANNING Updated Treatment Plan Timelines • “The counselor shall review and sign the updated treatment plan no later than 90 calendar days after signing the initial treatment plan and no later than every 90 calendar days thereafter, or when a change in problem identification or focus of treatment occurs, whichever comes first.” Section 51341.1(h)(2)(A)(iii)(a)

25. TREATMENT PLANNING Updated Treatment Plan Timelines “Within 15 calendar days of signature by the counselor, the physician shall review, approve and sign all updated treatment plans. If the physician has not prescribed medication, a psychologist licensed by the State of California Board of Psychology may sign an updated treatment plan.” Section 51341.1(h)(2)(A)(iii)(b)

26. TREATMENT MODALITIES • Outpatient Drug Free (ODF) • Day Care Rehabilitative (DCR) • Perinatal Residential

27. MODALITY REQUIREMENTS • ODF – Group counseling and limited individual counseling. Regular and perinatal. • DCR – Group and individual counseling. EPSDT and Perinatal ONLY. • Perinatal Residential – Group and individual counseling and other services. Perinatal ONLY. 16 or fewer clients Section 51341.1 (d)(1)-(4)

28. Definition GROUP COUNSELING • Face-to-face contact • One or more therapists or counselors • Two or more clients • Focused on the needs of the individuals • ODF – must be from 4 to 10 in the group • Non DMC clients can be in the group. Section 51341.1 (b)(8)

29. INDIVIDUAL COUNSELING IN ODF • ODF is a group counseling modality • Individual counseling is limited to five exceptions • Intake and assessment • Treatment Planning • Discharge Planning • Crisis Intervention • Collateral Services Section 51341.1 (d)(2)(B)

30. INDIVIDUAL COUNSELING (Cont’d) • Face-to-face contact • Telephone contacts, home visits and hospital visits do not qualify – services must be provided at the certified location Section 51341.1 (b)(9)

31. INTAKE (ASSESSMENT) INDIVIDUAL COUNSELING SESSION “Intake” means the process of admitting a beneficiary into a substance abuse treatment program. • The evaluation or analysis of the cause or nature of mental, emotional, psychological, behavioral and substance abuse disorders • The diagnosis of substance abuse disorders utilizing the DSM • The assessment of treatment needs to provide medically necessary treatment services. Any counseling session dealing with these topics is a valid Intake counseling session. Title 22, 51341.1(b)(10)

32. CRISIS INTERVENTION COUNSELING • Face-to-face contact with a beneficiary in crisis • Crisis is an actual relapse, or • Unforeseen event or circumstance causing an imminent threat of relapse • Services shall focus on alleviating crisis problems, and • Limited to stabilization of the emergency Section 51341.1 (b)(5)

33. COLLATERAL SERVICES COUNSELING • Face-to-face session • With persons significant in the life of the beneficiary • Personal, not professional, relationships • Focusing on the treatment needs of the beneficiary • Supporting the achievement of the beneficiary’s treatment goals Section 51341.1 (b)(3)

34. TREATMENT PLANNING COUNSELING SESSION • The process used to develop a treatment plan or update • May take more than a single session • May include assessment tools

35. DISCHARGE PLANNING • Actions to be completed by the beneficiary post treatment. • Progress note must document planning for continued recovery following discharge from the program.

36. DAY CARE REABILITATIVE • Outpatient counseling and rehabilitation services • Minimum of three hours a day, three days a week • Limited to pregnant or postpartum women, and/or • Early and Periodic Screening, Diagnosis and Treatment (EPSDT) eligible beneficiaries Section 51341.1 (b)(6)

37. Definition POSTPARTUM • A pregnant woman who was eligible for and received Medi-Cal during the last month of pregnancy • 60-day period beginning on the last day of pregnancy • Eligibility ends on the last day of the month in which the 60th day occurs. Section 51341.1 (b)(18)

38. DOCUMENTING TREATMENT • Treatment services must be documented through progress notes. • Progress note requirements are different for ODF and DCH/Perinatal Residential modalities.

39. DOCUMENTING TREATMENT Progress notes for ODF: • Must be legible • Must be individual narrative summaries • Must be completed for each counseling session • Must include attendance information including full date (month, day, year), session duration and type of counseling • Must include a description of beneficiary progress on treatment plan goals, etc. Section 51341.1 (h)(3)(A)

40. DOCUMENTING TREATMENT In DCR/Perinatal Residential, progress notes: • Must be legible • Must be individual narrative summaries • May cover up to seven days • Must include attendance information including full date (month, day, year), session duration and type of counseling for each counseling session • Must include a description of beneficiary progress on treatment plan goals, etc. Section 51341.1 (h)(3)(B)

41. EXAMPLES OF UNACCEPTABLE GROUP COUNSELING PROGESS NOTES: • Client attended “relapse prevention” group, clean and sober. Client participated. • Client attended “relapse prevention” group, c&s. Client verbally participated. Client has remained clean for 2 months (TXP prob 1). Client has scheduled GED test for next month (TXP prob 4)

42. BENEFICIARY & PROVIDER CONTACT • A minimum of two counseling sessions per 30-day period Section 51341.1 (h)(4)

43. BENEFICIARY & PROVIDER CONTACT Requirement may be waived by the provider if: • Fewer contacts are clinically appropriate • The beneficiary is making progress towards treatment plan goalsSection 51341.1 (h)(4) • “Exceptions or waivers must be noted, signed and dated by the physician in the beneficiary’s treatment plan.”Section 51341.1 (i)(4)

44. CONTINUING SERVICES JUSTIFICATION • No sooner than five months and no later than 6 months from admission or the date the last justification was completed. • Counselor must review progress and eligibility of beneficiary to continue services. Section 51341.1 (h)(5)(A)(i)

45. CONTINUING SERVICES JUSTIFICATION (Cont’d) • The physician must determine the need for continuing services based on: The counselor’s recommendation The beneficiary’s prognosis The medical necessity of continued treatment Section 51341.1 (h)(5)(A)(ii)

46. CONTINUING SERVICES JUSTIFICATION (Cont’d) • The beneficiary must be discharged from Drug Medi-Cal if the physician determines that there is no medical necessity to continue treatment. • If the justification to continue services is missing from the patient record, all billings submitted after the date that the justification was due will be disallowed. Section 51341.1 (h)(5)(A)

47. CONTINUING SERVICES JUSTIFICATION (Cont’d) • The justification for continuing services is the third component that establishes medical necessity.

48. DISCHARGE • Discharge may be voluntary or involuntary • A discharge summary must be completed within 30 calendar days of the last face-to-face treatment contact • The summary must include: • The duration of the treatment episode • The reason for discharge • A narrative summary of the treatment episode • The beneficiary’s prognosis Section 51341.1 (h)(6)(A)

49. Additional components of a discharge summary based on the Treatment Standards: • Current drug usage • Vocational/educational achievements • Legal Issues • Beneficiary’s discharge plan • Referrals

50. DISCHARGE – FAIR HEARING • Any action taken to terminate or reduce services to a Medi-Cal beneficiary can be appealed by the beneficiary through a fair hearing process. • This fair hearing is in addition to any program or county level fair hearing process. Section 51341.1 (p)