Service Documentation Workshop

1. Service Documentation Workshop Presented as part of the Test Site Project for the 2004 Real Choice Grant Integrating Long-Term Supports with Affordable Housing DHS AMH Division October 15, 2007

2. Presented by: Terry N. Mastin, M.A.Housing Supports Reform SpecialistAddictions and Mental Health DivisionOregon Department of Human Services Terry.n.mastin@state.or.us 503-945-6722 DHS AMH Division October 15, 2007

3. An 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? DHS AMH Division October 15, 2007

4. Section I How are the services you provide to the people in the community paid for? DHS AMH Division October 15, 2007

5. Medicaid Title XIX of the Social Security Act is a Federal/State entitlement program that pays for medical assistance for certain individuals and families with low incomes and resources. Medicaid, became law in 1965 as a cooperative venture jointly funded by the Federal and State governments to assist States in furnishing medical assistance to eligible needy persons. Medicaid is the largest source of funding for medical and health-related services for America's poorest people. DHS AMH Division October 15, 2007

6. Medicaid Within broad national guidelines established by Federal statutes, regulations, and policies, each State:(1) establishes its own eligibility standards (2) determines the type, amount, duration, and scope of services (3) sets the rate of payment for services(4) administers its own program DHS AMH Division October 15, 2007

7. 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. (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. DHS AMH Division October 15, 2007

8. 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 Community Mental Health Programs Mental Health Organizations Community Mental Health Provider DHS AMH Division October 15, 2007

9. A Different View…………………….. Title XIX Medicaid Oregon State Medicaid Plan Oregon Health Plan and Psychiatric Long Term Care MHOs, CMHPs, & Mental Health Providers Consumers, Peers, Staff DHS AMH Division October 15, 2007

10. Another angle…. Consumers, Peers, Staff MHOs, CMHPs, & Mental Health Provider Agencies, Oregon Medicaid State Plan, OHP, PLTC Medicaid, Title XIX DHS AMH Division October 15, 2007

11. Section II What are the overall requirements for providing services? DHS AMH Division October 15, 2007

12. Medicaid Documentation EEK......An Audit! • 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. DHS AMH Division October 15, 2007

13. 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. DHS AMH Division October 15, 2007

14. 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 staff 9. 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. DHS AMH Division October 15, 2007

15. Medicaid Documentation Where to look for documentation requirements? DEPARTMENT OF HUMAN SERVICES, ADDICTIONS AND MENTAL HEALTH DIVISION: MENTAL HEALTH SERVICES OREGON ADMINISTRATIVE RULES DIVISION 16 MEDICAID PAYMENT FORREHABILITATIVE MENTAL HEALTH SERVICES DHS AMH Division October 15, 2007

16. 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 DHS AMH Division October 15, 2007

17. Medicaid Coverage: Documentation ASSESSMENT TREATMENT PLAN PROGRESS NOTE DHS AMH Division October 15, 2007

18. Another view………….… ASSESSMENT TREATMENT PLAN PROGRESS NOTE DHS AMH Division October 15, 2007

19. Assessment What are the minimum requirements for an assessment? DHS AMH Division October 15, 2007

20. Assessment • Done by QMHP during enrollment, and • Updated annually • Reviewed and approved by LMP at least annually • DSM five axes diagnosis • Clinical formulation DHS AMH Division October 15, 2007

21. Assessment (cont.) • Includes treatment domains: Cognitive Family Substance Abuse Emotional Behavioral Developmental Social Physical health/medical care Nutritional School or Vocational Cultural Legal DHS AMH Division October 15, 2007

22. Treatment Plan What are the minimum requirements for a Treatment Plan? DHS AMH Division October 15, 2007

23. Treatment 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. DHS AMH Division October 15, 2007

24. 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. DHS AMH Division October 15, 2007

25. Progress Notes What are the minimum requirements of a Progress Note? DHS AMH Division October 15, 2007

26. Progress Note • Thespecific 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. DHS AMH Division October 15, 2007

27. 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. DHS AMH Division October 15, 2007

28. 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. DHS AMH Division October 15, 2007

29. Section III How can you document the services you provide correctly? DHS AMH Division October 15, 2007

30. 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.” DHS AMH Division October 15, 2007

31. Remember?.................... ASSESSMENT TREATMENT PLAN PROGRESS NOTE DHS AMH Division October 15, 2007

32. 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. DHS AMH Division October 15, 2007

33. Variances A variance from those requirements not established by federal regulations may be granted for up to one year by submitting a written request including: • Section of the rule • Reason • Alternative practice • A timetable for compliance to the AMH Medicaid Policy Unit DHS AMH Division October 15, 2007

34. Document Packet • YCAMH Adult Behavioral Health Assessment • Sample Letter from a Collateral Source • YCAMH Continued Service Request/Continuum of Care Plan • YCAMH Residential Services Treatment Plan Addendum DHS AMH Division October 15, 2007

35. What is a clinical formulation? • Break into small groups. • Example of clinical formulation in packet. • Read “Sample Letter from a Collateral Source.” • Come up with a clinical formulation, as a group, using that scenario. DHS AMH Division October 15, 2007

36. Treatment Plans • Rejoin your small group. • Compare the minimum requirements for a treatment plan to the YCAMH Continued Service Request/Continuum of Care Plan and the Residential Services Treatment Plan Addendum. • What requirements are met? • Any required elements missing? DHS AMH Division October 15, 2007

37. Progress Notes • As a large group, generate some scenarios on the services/supports you provide in a typical day. • Provide a progress note for each scenario that contains the minimum requirements for a progress note, per the Oregon Administrative Rules, Division 16. DHS AMH Division October 15, 2007

38. Evaluation 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! DHS AMH Division October 15, 2007