Dec 6, 2012 ... System of Care (CYF), Adult/Older Adult System of ... Accurate Documentation of
Assessment, Treatment Plan of Care, and Progress Notes ........... 12 .... Examples
of Medi-cal and Medicare Assessment Progress Notes . .... Distinction Between
Group Psychotherapy and Group Rehabilitation Services .
OUTPATIENT SERVICES DOCUMENTATION STANDARDS AND PRACTICES
Introduction This manual has been developed as a resource for providers of San Francisco Department of Public Health, Community Programs (SFDPH, Community Programs). It outlines standards and practices required within the Children, Youth and Family System of Care (CYF), Adult/Older Adult System of Care (AOA), the Private Provider Network (PPN), Substance Abuse, and Primary Care. This manual will be posted at the following web site: http://www.sfdph.org/ As with any manual, updates will need to be made as policies and regulations change. When updates are distributed, please be sure to replace old sections with updated sections. Information or support regarding SF Avatar, the Behavioral Health Electronic Health Record System can be found at the following link: Click Here Any questions, concerns or comments regarding this manual should be directed to the DPH Compliance Office 415-255-3706.
San Francisco Department of Public Health, Community Programs 1380 Howard Street, 5th Floor San Francisco, CA 94103 Tel: (415) 255-3400 Fax: (415) 255-3567
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ACKNOWLEDGMENT: The DPH Office of Compliance and Community Behavioral Health Services would like to express their heartfelt gratitude to the many individuals who have contributed endless number of hours to making this project possible. We offer a warm and grateful thank you to the following contributors, for their many insights, wisdom and expertise, and for their rigorous proofreading and editing this manual. Maria Barteaux Hung-Ming Chu, MD Miriam Damon, RN, MFT Susan T. Esposito, LCSW Alice Lee, MPH Richard Look, IS Engineer Ravi Mehta, PsyD Chona Peralta, LCSW Lisa Scott-Lee, EdD, MFT Irene Sung, MD Gloria Wilder, PharmD
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Table of Contents Behavioral Health Services Section 1: Compliance Compliance with Billing Codes ......................................................................................................... Most Frequent Billing Codes ........................................................................................................... Variances between billing Codes ..................................................................................................... Other Guidelines for Coding and Billing ......................................................................................... Signatures- Certification/Verification/ National Provider Identification Number ..................
9 10 10 10 11
Section 2: General Principles of Documentation and Billing of Services Electronic Health Record ................................................................................................................... 12 Accurate Documentation of Assessment, Treatment Plan of Care, and Progress Notes ........... 12 Avatar Error Correction Procedures/Billing Corrections................................................................ 13 Service Codes and Reporting Units .................................................................................................. 13 Face–to-Face/Total Time .................................................................................................................. 13 Timelines ............................................................................................................................................. 13 Provider’s Role in the Billing Process................................................................................................. 14 Readable/Legible - Spellcheck/Abbreviations/Acronyms .............................................................. 14 Two or More People Providing Services ......................................................................................... 14 Progress Note Standards .................................................................................................................. 15 Restrictions/Exclusions in the Electronic Health Record .............................................................. 15 Evidence of Consent .......................................................................................................................... 15 Confidentiality ................................................................................................................................... 15 PIRP Format ........................................................................................................................................16 Legal Sanctions .................................................................................................................................. 17 Non-Billable Services ......................................................................................................................... 17 Concerns or Complaints ................................................................................................................... 17
Section 3: Medical Necessity Description/Definition ..................................................................................................................... 18 Clinical Pathway to Document Medical Necessity ......................................................................... 18 CCR, Title 9 Description ............................................................................................................. 19-20
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Table of Contents Section 4: Specialty Mental Health Services CCR, Title 9 Description of Specialty Mental Health Services ................................................. 21-23 Diagram: Treatment Cycle of Providing Services ............................................................................ 24
Section 5: Treatment Documentation A. Assessment Description- CCR, Title 9 Requirements ........................................................................................ 25 Elements of an Initial Assessment .................................................................................................. 25 Diagnostic Formulation ................................................................................................................... 26 Assessment/Evaluation Frequency .................................................................................................. 26 Coding, Documentation and Billing of Assessment Services ..................................................... 27 Examples of Medi-cal and Medicare Assessment Progress Notes ........................................ 27-30
B. Treatment Plan of Care Description- CCR, Title 9 Requirements .................................................................................... Key Points of Treatment Plan of Care ............................................................................................. Relationship Between Goals/Objectives ........................................................................................ Interventions ..................................................................................................................................... Treatment Plan Examples of Goals/Objectives & Interventions .................................................... Updates ................................................................................................................................................ Timelines/Frequency of Client Treatment Plan of Care (General) ............................................... Signatures and Dates ........................................................................................................................ Treatment Plan of Care and CANS (Child and Youth) ...................................................................
31 31 31 32 33 34 34 35 36
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Table of Contents C. Documentation of Ongoing Services 1. Plan Development CCR, Title 9 Description .................................................................................................................. Consultation ...................................................................................................................................... Consultation versus Supervision .................................................................................................... Documentation of Consultation .....................................................................................................
37 38 38 38
2. Individual Therapy CCR, Title 9 Description .................................................................................................................. Codes Used to Bill Individual Services ........................................................................................... Individual Psychotherapy ............................................................................................................... Medical Record Cloning ............................................................................................................... Individual Psychotherapy - Interactive ..........................................................................................
39 39 39 39 40
3. Group Therapy and Group Rehabilitation CCR, Title 9 Description .................................................................................................................. 41 Codes Used to Bill Group ................................................................................................................ 41 Distinction Between Group Psychotherapy and Group Rehabilitation Services ......................... 41 Documentation of Groups ............................................................................................................... 42 90849 Multiple Family Groups .......................................................................................................... 43 90853 Group Psychotherapy .............................................................................................................. 43 90857 Group Therapy/Interactive ..................................................................................................... 43 H2015GT Group Therapy/Rehabilitation ........................................................................................ 43 Sample of Medi-Cal and Medicare Group Progress Notes (90853)............................................... 44 Example of Avatar Group Progress Notes.......................................................................................... 45
4. Collateral Services CCR, Title 9 Description .................................................................................................................. 46 Codes used to Bill Collateral Services ............................................................................................ 46 90846 Family Therapy without Client Present ................................................................................. 46 90847 Family Therapy with Client Present ....................................................................................... 46 H2015CI Collateral (Individual Rehab) .......................................................................................... 47 H2015CG Collateral (Group Rehab) ............................................................................................... 47 Sample Collateral Progress Notes ............................................................................................... 47-48
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Table of Contents C. Documentation of Ongoing Services (cont.) 5. Case Management Services
CCR, Title 9 Description .................................................................................................................. Codes Used to Bill Case Management Services ............................................................................. 90882 Environmental Intervention ................................................................................................. 90885 Record Review for Report ..................................................................................................... 90887 Interpret and Explain Psychiatric Information ................................................................... 90889 Psychiatric Report Preparation (CPT User) .......................................................................... T1017 Report Preparation (HCPCS User) ...................................................................................... Case Management Lockouts ........................................................................................................... Sample Case Management Progress Notes (Inpatient) ...................................................................
6. Medication Services Including Evaluation and Management
CCR, Title 9 Description .................................................................................................................. Scope of Practice ................................................................................................................................ Frequently Used Codes ..................................................................................................................... 90862 Pharmacological Management with Minimal Psychotherapy .......................................... M0064 Brief Medication Visit (Office/Clinic setting only)............................................................ 90805 Individual Therapy w/ E&M (20-40 mins) ......................................................................... 90807 Individual Therapy w/ E&M (45-74 mins) .......................................................................... 90811 Interactive Individual Therapy w/ E&M (20-44 mins) ....................................................... 90813 Interactive Individual Therapy w/ E&M (45-74 mins) ....................................................... 90801 Psychiatric Diagnostic Interview Examination .................................................................. H2010MT (HCPCS) Medication Support Services ....................................................................... Sample Medication Support Progress Notes ................................................................................... One-Shot Medication Support Services ............................................................................................ Lockouts/Limits for Medication Support Services .......................................................................
49 49 49 50 50 50 50 51 51 52 53 53 54 54 55 55 55 55 55 56 57 58 58
7. Day Treatment & Adult Residential Treatment Services - see Appendix F ........................ 59 8. Crisis Intervention CCR, Title 9 Description .................................................................................................................. Crisis Intervention ........................................................................................................................... Lockouts for Crisis Intervention .................................................................................................... Crisis Intervention Addenda Documentation Guidance ...............................................................
9. Other Supplemental Mental Health Services
60 60 60 61
Therapeutic Behavioral Services ....................................................................................................... 62
10. Discharge/Closing Summary ............................................................................................ 63 11. Clients in Hospital, IMD, MHRC, PHF or SNF .................................................................. 63 12. Clients Who are Incarcerated ............................................................................................ 64
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Table of Contents Section 6: Appendices Appendix A: Mental Health Staffing Qualifications for Service/Billing Privileges ..................................................... 65 Appendix B: Procedures for Certification and Verification........................................................................................... 66 Appendix C: Avatar Service Codes .................................................................................................................................. 70 Appendix D: Correcting Service Posting: Edit Service Information w/Screen Shots/Guarantor Information ............ 73 Appendix E: Adult/Older Adult Timeliness and Frequency Treatment Plan Memo..................................................... 74 Appendix F: Day Treatment & Adult Residential Treatment Services ......................................................................... 75 Appendix G: Included and Excluded Diagnoses............................................................................................................. 87 Appendix H: DHCS Reasons for Recoupment ............................................................................................................... 88 Appendix I: Approved Abbreviations and Acronyms ................................................................................................... 92 Appendix J: CPT Coding Changes for 2013................................................................................................................... 108
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Section 1: Compliance San Francisco Department of Public Health, Community Programs (SFDPH, Community Programs) has adopted a Compliance Plan to adhere to the State and Federal laws and regulations. In response to Medicaid/Medicare fraud and abuse, the external compliance reviews of service claims and documentation have increased exponentially. Severe sanctions are being enforced against entities that are out of compliance with professionally recognized operating standards or misrepresent services provided, service codes billed, or practitioners not authorized to provide certain services. This manual has been assembled to ensure that services and providers of SFDPH, Community Programs meet regulatory and compliance standards of competency, accuracy, and integrity.
“Compliance” is accomplished by: • • • •
Adherence to legal, ethical, code of conduct and best-practice standards for billing and coding, and documentation. Participation by all providers in proactive training and quality improvement processes. Working within your professional scope of practice. Having a Compliance Plan to ensure there is accountability for all SFDPH, Community Programs activities and functions. This includes the accuracy of progress note documentation by defined practitioners who will select correct service codes to support the documentation of services provided.
Please refer to the following link for additional information regarding DPH Compliance: Click Here It is critical that you understand and comply with the accurate use of billing codes and documentation standards that are presented in this manual.
Compliance is not optional!
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Section 1: Compliance Compliance with Billing Codes National Codes: There are two different types of national codes. These are service codes and diagnosis codes. In order to move toward the use of consistent codes nationally, all healthcare organizations, private and public, must ultimately use the nationally recognized code sets. HCPCS Codes (Services): Healthcare Common Procedural Coding System (HCPCS) are service codes. They are divided into two groups – Level I and Level II codes: o Level I codes are also known as Current Procedural Terminology (CPT). o Level II codes are a mixture of Alcohol and Drug Treatment Codes, Rehabilitation, and other material and services codes. Level I-CPT: CPT is published by the American Medical Association and is the defining industry standard for all services and procedures provided in a variety of healthcare settings by a number of different types of providers. CPT codes are five digit numeric sequences, each defining a particular service or procedure. Level II-HCPCS: HCPCS codes, for the purposes of SFDPH, Community Programs and its providers, use these codes for services that are: 1) 2) 3) 4)
Provided by a staff person who is not eligible to use the CPT codes. Unique to California and therefore must fall into a broad national service category. Provided over the phone. Considered a Collateral service (similar to Family Psychotherapy with or without the client present) that is provided by a person that is not considered a member of the “family” per the definitions. Click Here
The Level I-CPT: CPT codes may only be used by certain licensed, waived, or registered staff. In fact, some CPT codes may only be used by Nurse Practitioners (NP)and Physicians (MD/DO) Refer to: Mental Health Staffing Qualifications for Service/Billing Privileges) Appendix A The Level II-HCPCS: HCPCS codes may be used by all service practitioners. Please NOTE: If your discipline is included in the CPT Users list it is the expectation of SFDPH, Community Programs, that a CPT code will be used, unless there is no CPT code that accurately reflects the service that you provided (e.g. Plan Development and certain Service Locations).
Level I-CPT Users: Refers to the following staff: MDs/DOs, NPs, LCSW, MFT, PhD, PsyD, CNS, registered (MFT Intern and ASW), and waived staff (Ph.D/Psy.D. registered with California Department of Health Care Services). Level II-HCPCS Users: Refers to all other staff that may provide services, including but not limited to: RN, LVN, LPT, Pharmacists, OTR, and non-licensed, non-registered and non-waived staff including student/trainee, MA/MSW.
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Section 1: Compliance Most Frequently Used Billing Codes:
SFDPH, Community Programs maintains a document outlining service billing codes and CPT/HCPCS code(s) for SFDPH, Community Programs providers. Sometimes the location of the service (school is a location where a CPT code cannot be used) and/or discipline of a provider (trainee) will determine which service codes can be used. The reference for Avatar Service Codes can be found in Appendix C or at the following link: Click Here
Variances Between National Codes:
While State Medi-Cal regulations require that providers claim for most services by the minute, several CPT codes are distinguished by a usual and customary fee for the procedure provided. Therefore, it is essential that you pay attention to the face-to-face time that a session lasted so that you are using the appropriate national CPT code. This face-to-face time will determine what CPT code you choose to use. • Example I- for individual psychotherapy, if your face-to-face (FTF), direct service time, falls between the times allotted for a CPT code, always choose the CPT code for less time (i.e., claiming 90804, for services 20-44 mins. versus claiming 90806, for FTF services lasting between 45-74 mins.). • This applies only to those direct service codes that have a specified timeframe for the service (e.g., 90804, 90805, 90806, 90807, 90808, 90809, 90810, 90811, 90812, 90813, 90814, 90815). • Example II- for Medi-Cal clients: A therapist provides individual therapy for a client face-to-face (FTF) for 40 minutes. The therapist then documents the service, which takes 7 minutes. On his progress note, under FTF/Total Time duration [TT], (per Avatar-also known as “Total Time”), the therapist documents 40/47. The CPT code that he uses is 90804, because this code is used for any FTF therapy session between 20 and 44 minutes.
Other Guidelines for Coding/Billing: •
Do not select the location code of ‘phone’ for clients on Medicare. Medicare requires a face-to-face contact; instead bill to a HCPCS code.
•
Treatment Meetings, Case Conferences, Consultation services, developing the POC, and discussion of POC goals are billed as HCPCS code H2015AP –Plan Development.
•
Case Management/Brokerage and Linkage are billed as HCPCS and CPT codes according to location and staff privileges.
•
Collateral Services provided to individuals who are not “Family” members (using Medicare’s definition) must be billed using HCPCS code H2015 Cl – Collateral-Individual.
•
Use the CPT Family Psychotherapy codes 90846 when client is not present & 90847 when the client is present
•
Although Title 9 defines family broadly, the definition used by Medicare is narrow, and must be followed for the purpose of billing. "Family" as defined by Medicare, may apply to traditional family members (including husband, wife, siblings, children, grandchildren, grandparents, mother, father), live-in companions, or significant others involved in the care of the patient. This includes a primary caregiver who provides care on a voluntary, uncompensated, regular, sustained basis, guardian, or health care proxy. Services to other significant support persons in a client’s life are considered “Collateral” services in Medi-Cal is identified by the client themselves, or the person providing services. Facility staff members are not considered significant others in Medicare claiming.
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Section 1: Compliance Signatures:
In order to provide a service and bill for a service, all clinicians must have a CBHS Staff ID. The procedures to obtain a Staff ID, Certification and Verification form for Staff ID can be found in Appendix B or this link: Click Here It is mandatory for each clinician to obtain a National Provider Identification Number (NPI) in order to provide/bill for a service. NPI number is required by the State Department of Mental Health and SFDPH, Community Programs requires a NPI number prior to hire or contract. The process of obtaining an NPI number is done online. To obtain an NPI number: Click Here
Each clinician signature must have a title (discipline – e.g., ASW, MD, MFT Intern, LCSW, MFT, MHRS, etc). The Avatar Account Manager maintains a file of clinician unique identifiers/signatures. ➢➢ Your signature must be on file in order to use the Electronic Health Record (EHR). ➢➢ Authentication – CBHS maintains a signed Electronic Signature Agreement for the terms of use of an electronic signature signed by both the individual requesting electronic signature authorization and the CBHS Director or designee. Electronic signatures based on login name and password are valid for six (6) months. Renewal of the password renews the electronic signature agreement. ➢➢ Agencies wanting to use their own electronic signatures must provide SFDPH, Community Programs with policies and procedures on electronic signatures.
The websites for CBHS Policies and Procedures are: ▶▶ DPHNet Homepage: This Menu page is accessible only to DPH staff – Under the Menu, click Policies; click Community Behavioral Health Services: Policies & Procedures Manual ▶▶ Providers who do not have access to DPHNet Homepage. DPH Public Site is: Click Here Scroll down to “Other Information” for “Community Behavioral Health Services- Policies & Procedures Manual”.
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Section 2: General Principles of Documentation and Billing of Services How Electronic Health Records Affects You, The Provider As a service provider for clients within the SFDPH, Community Programs system, it is critical that you understand and comply with the standards outlined in this manual. For the submission of claims at the State and Federal levels to be accurate, each individual clinician/service provider must understand and follow the requirements for documentation and billing. The following are just a few areas that providers must be aware of in relation to documentation:
FRAUD: “an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other persons.” (42 CFR §455.2)
Accurate Documentation of Assessment, Treatment Plan of Care, and Progress Notes 1. On July 1, 2010, Community Behavioral Health Services (CBHS) implemented Avatar, an Electronic Health Record (EHR) system. Until the EHR is completely electronic, CBHS continues to maintain a hybrid health record system, which includes both paper-based and electronic documents. For new client admission and re-admission in Avatar, the hybrid health record continues to include chart forms that require client’s signature and other pertinent paper-based documents until signature pads and/or scanning capabilities become available. 2. Submit an accurate assessment, Treatment Plan of Care, and Progress Notes. Avatar Electronic Health Records are legal documents and it is required that all staff make every effort to ensure that all clinical docu-mentation are accurate. 3. Only bill for services with a progress note written in Avatar. Do not bill for a service for which you have not completed a progress note. This leads to fradulent billing practices. Services will be disallowed in an audit and State and Federal agencies will file fraud charges in response to such practices. 4. Each progress note must “Stand Alone” and documentation should clearly support medical necessity for Specialty Mental Health Services. 5. The progress note must support the CPT or HCPCS code used for billing. 6. If a staff member notices an error in a progress note related to billing that could result in an inaccurate claim, it is the personal responsibility of that staff member to correct the error.
See Complete List for Reasons for Recoupment Click Here
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Section 2: General Principles of Documentation and Billing of Services Avatar Error Corrections: Billing corrections in Avatar depends on the billing status Billed/Claimed vs. Unbilled/Open – always review the “client account ledger” for status of billing. ➢➢ Unbilled/Open status – Provider goes to Edit Service Information and make the changes. ➢ Claimed - submit a completed BH7019 (aka 1984) for both mental health and substance abuse to CBHS Billing Unit. For information and support related to Correcting Service Posting: Edit Service Information (i.e. change of location service), See Appendix D. Click Here
7. Service Codes and Reporting Units Service Codes are configured for specific reporting units. Be sure that the service code for your documentation is in the drop down list of available codes that have been set up for your reporting unit. If a service code is not in the drop down list- please notify your supervisor who will notify CBHS Contract Development Technical Assistance. 8. Face -to-Face (FTF) and Total Time (TT) of Services Each note should contain both the face-to-face time (direct service time) and the total time for the service (Avatar automatically calculates Total Time. Total time is the combination of face-to-face time, and administrative time (used for documentation and travel). This combination is billable to Medi-Cal. 9. CPT Coding CPT users must use the correct code in a progress note that represents only the face-to-face (direct) time spent providing the service, and NOT a combination time that includes the administrative time. Note: Avatar configures the duration automatically depending on the code the clinician selects. 10. Timelines of Service Each Service contact is documented in a progress note and documentation must be finalized in a timely manner. ➢➢ A progress note is completed for each service contact, except Rehabilitative Day Treatment which requires a weekly progress note summary and Intensive Day Treatment which requires completion of a daily progress note AND weekly progress note summary. PROGRESS NOTE TIMELINE : Progress notes must be completed in a timely manner according to the following guidelines. ▶▶ Every effort should be made to complete progress notes on the same day as the session. ▶▶ Individual Notes must be finalized within 5 business days from the date of service. ▶▶ Group Notes must be finalized within 5 business days from the date of service. For group notes billing, staff must make sure that there is a group note and an individual note for each client in the group. See Avatar Group Notes Instruction. ▶▶ Co-Sign Notes must be finalized within 5 business days from the date of service. If the supervisor is not available, interns/staff must coordinate with the program director or other designated supervisors for reviewing notes and other clinical documents for co-signature. ▶▶ After 5 business days, label “late entry” at the beginning of the note.
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Section 2: General Principles of Documentation and Billing of Services 11. Provider’s Role in Documenting Services
It is crucial that the staff providing the service records the correct code for the service provided and the documentation supports and substantiates this service. ▷▷ The provider’s documentation of the service provided will drive the billing of that service. ▷▷ SFDPH, Community Programs have multiple levels of checks and reviews of billing, however, no set of safeguards, reviews, or double checks can result in an accurate bill being submitted if the documentation does not accurately represent the service provided. ▷▷ The provider is personally responsible to accurately and thoroughly document the service provided by following the Billing Process described below:
THE BILLING PROCESS Deliver the Service
Document Service in Progress Note
Use Correct Code to support Service
Bill the Service Code
12. To receive the correct reimbursement, clinicians must choose to document the correct service code in the
correct program code/reporting unit (RU) and on the correct client.
13. Readable and Legible Documentation must be readable and legible. The spell check function of your
computer must be turned on (go to tools/select the spell check function). In Avatar, go to preferences, general tab and select “standard spell check,” near the bottom of the page select the button to “always check spelling from start of text.” In an Avatar free text box, you can right click in the text field to bring up the spell check function. When Documenting a Service for Two or More People
Define the role of the others involved in the Service When the Service involves another professional
When the Service involves another client When the Service involves a family member of support persons When Services involve two or more clients who are also family members
e.g. the client’s mother participated in the session. Use the name & role of the professional, e.g. Jane Smith, Probation Officer. Do NOT write a client’s name in another client’s chart. Use a first name or relationship to client (e.g. older sibling). Limit what you say about family members. It is not their chart. Write a note for each client & split the time accordingly.
Regulatory/Compliance Standards for Documentation and Billing of Progress Notes: NOTE: MEDICARE CLAIMING Although the predominant payer for services provided to our adult clients remains Medi-Cal, it is critical that we are scrupulous in documenting services for clients who are insured by Medicare, or who have Medicare/Medi-Cal coverage. Accurate claiming is necessary for full compliance with State and Federal law. Even though Medicare and Medi-Cal both utilize Federal dollars, they do not follow the same rules. Medicare will reimburse for services according to strict defin tions, using a medical model that does not emphasize a rehabilitative focus. Only face-to-face time is reimbursable to Medicare. We cannot submit claims for the time spent on the telephone, documenting services, or in collaboration unless connected to a face-to-face service. The ey to Medicare compliance is through the use of correct service charge codes and by accurately recording the location where services are provided.
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Section 2: General Principles of Documentation and Billing of Services REMEMBER: Progress notes are legal documents Progress Note Standards In order to meet regulatory and compliance standards: A. Progress Notes: • Must be related to the client’s progress in treatment •
Must provide timely documentation of relevant aspects of client care
•
Must document: ➢➢ Client encounters ➢➢ Interventions ➢➢ Follow up care ➢➢ Clinical decisions ➢➢ Client’s response to interventions ➢➢ New Assessment Information ➢➢ Referrals to community resources
➢➢ And be signed by the person providing the service, including professional degree, licensure or job title ➢➢ Date services were provided ➢➢ If service is provided in client’s primary language, document the language and the name of the interpreter in the progress notes.
1. Progress notes are the method by which other treatment team members, or other reviewers (such as the State, Federal or contracted reviewers) are able to determine medical necessity and level of care/treatment for the client. 2. The client’s presenting signs, symptoms or other clinical problems should clearly support the need for a particular service. 3. Each progress note must have components that show what has been done to help a client reach their goal. B. Restriction of Client Information: Quality of Care Reports, Incident Reports, Grievances, Notice of Action, PURQC (Program Utilization Review Quality Committee) recommendations or forms and audit worksheets should never be scanned into the electronic health record, or filed in paper record or billed. C. Evidence of Consent: Consent for Treatment, Consent for Medication, Releases of Information are maintained in a paper record until signature pad/scanner is purchased/utilized by SFDPH, Community Programs. D. Confidentiality: Clinicians must adhere to all Federal and State laws and regulations regarding HIPAA, and security/privacy of documentation whether it is in paper or electronic form.
14. Every Billing Must be Documented by a Progress Note
It is not enough to document that you have seen the client – SFDPH, Community Programs has adopted the P.I.R.P. format which enables service providers to utilize progress notes as a communication tool that will provide a clear picture of services and client status. P.I.R.P. is an acronym for:
▶▶ Problem (in that session) ▶▶ Intervention (provided by staff) ▶▶ Response (of the client in that session, and to the interventions) ▶▶ Plan (next appointment, homework assignments, clinical decisions, collateral, referrals, etc.) If you have updated the plan of care/treatment plan, goals/objectives, or interventions, or it is part of your plan to do so, please reference your plans/ updates in the progress note.
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Section 2: General Principles of Documentation and Billing of Services The Problem: Use a clear and complete notation or description regard-
Problem
ing the client’s current complaint(s), condition(s), assessment of client and/or reason(s) presented during the session. Use behavioral terms, and include an assessment of the client. This is not a statement of diagnosis but rather a statement of why this session is necessary. •
Is progress being made?
•
Any remaining impairments?
•
Is the diagnosis still valid?
The Intervention: Use descriptive sentence(s) about staff’s interven-
Intervention
tions (what you did). Identify skills used to cope/adapt/respond/problem solve. Reinforce new behaviors, strengths. Identify specific skills that are taught/modeled/practiced. The Intervention elements of the progress note shall describe the following: •
Clinician’s interventions
•
Clinician’s assessment, including a risk assessment when applicable
•
Document advice/recommendations given to client/family
The Response of the Client to Staff Intervention: Use
Response
descriptive sentences about the client’s response to the staff’s intervention; describe the response to the intervention in behavioral terms and include the client’s progress or lack of progress. Intermittently document the client’s progress or lack of progress towards the Plan of Care goals. The Response may also include a description of other significant changes in client status. Any new assessment findings? If there is a lack of improvement: • Explain the reason for the lack of improvement •
Obtain a consultation, if needed, to verify the diagnosis or treatment plan
•
Explain the need for additional treatment due to Medical Necessity
•
Include outcome measures in documentation, as appropriate
The Plan: The Plan component outlines clinical decisions regarding the
Plan
POC, collateral contact, referrals to be made, follow-up items, homework assignments, treatment meetings to be convened, etc... Any referrals to community resources and other agencies when appropriate, and any follow-up appointments may also be included. • Are new goals needed? •
Document that the treatment goals remain appropriate, or revise as needed.
•
Consider treatment titration and plan for discharge.
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Section 2: General Principles of Documentation and Billing of Services 15. Legal Sanctions for Improper Documentation and Billing
The Office of Inspector General (OIG) is primarily responsible for Medicare and Medicaid fraud investigations and provides support to the U.S. Attorney’s Office for cases which lead to prosecution. The State of California has a Medicaid/Medicare Fraud Control Unit. Many California county mental health departments have already been investigated by State and Federal agencies, and in all of the counties either severe compliance plans or fraud charges have been implemented.
16. Some services are not claimable. Non-Reimbursable codes and certain location codes block the service from being billed. Unclaimable services are meant to include a wide variety of potential service deemed necessary to recovery and resiliency but are not reimbursable as Mental Health or other claimable clinical services. This category of non-billable service codes permit flexibility in treatment planning and promotes the adoption of recovery-based services to individual clients. These services should be documented by all staff working with clients.
Non-Billable Services ▷▷ Transportation of client with no mental health service provided ▷▷ Leaving or listening to voicemail messages and sending/receiving faxes or emails ▷▷ Scheduling appointments ▷▷ Missed visit (No Show/Client not a home) ▷▷ Interpretation/Translation only (without a service documented) ▷▷ Client in an IMD, Psychiatric Skilled Nursing Facility, Psychiatric Hospital (unless for targeted case management for purposes of placement)
▷▷ Adult client in jail ▷▷ Youth or Transition Aged Youth in Juvenile Hall or Facility (unless they are adjudicated for placement; court order must be in chart) ▷▷ Assistance provided to family members seeking needed services for him/herself ▷▷ Ongoing Rep-Payee/Subpayee functions such as requesting checks ▷▷ Letter excusing client from jury duty/testifying, waiting in court ▷▷ Closing a chart (client abandons service or passes away)
NOTE: “Travel” is not “Transportation.” Travel involves the provider going from his/her location, to the location where a service will be provided. Transportation involves the provider taking the client/family from one location to another. If a “behavioral health service” is provided during the time a provider is transporting the client/family, then the time spent providing the service is not “transportation” and that portion of service time can be claimed.
Concerns/Complaints County employees have a personal obligation to report in good faith known or suspected violations of any statute, regulation or guideline applicable to the federal healthcare programs, any law or regulation, or policies and procedures to their supervisor, manager or other management staff
ABUSE: “provider practices that are inconsistent with sound fiscal, business or medical practice, and result in an unnecessary cost to the Medicaid (Medi-Cal) program, or in reimbursement for services that are not medically necessary”
The goal of SFDPH, Community Programs is to promote a culture of quality, integrity, accountability and compliance for all fiscal, administrative and clinical functions of the organization. As the provider of services, your understanding and integration of these standards and guidelines into your practice, demonstrates your commitment to SFDPH, Community Programs in achieving these goals.
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Section 3: Medical Necessity Medical Necessity for Medi-Cal Specialty Mental Health Services Medical Necessity and Functional Impairments must be determined and documented throughout the assessment. The assessment must identify that behavioral symptoms of the most current DSM included diagnosis are serious enough to disrupt the client’s ability to cope with or master various age and culture related social, personal safety, occupational or behavioral role functions.
Document Medical Necessity by... ▷▷ Stating target symptoms and diagnosis ▷▷ Stating the level and severity of impairment and its relationship to the included diagnosis ▷▷ Stating the level and severity of disruption of social and other role functions that are due to symptoms from the included diagnosis ▷▷ Describing how the interventions are reducing either the impairment of functioning or the symptoms that are causing impairment in functioning ▷▷ Stating the focus of treatment as evident by choice of goals/ objectives and addressing these goals and objectives in progress notes
Functional Impairment Evaluation
Pertains to the client’s quality of life and whether the client’s mental illness impacts this quality of life in the following areas: ▶▶ Living situation ▶▶ Daily activities and functioning ▶▶ Family relations ▶▶ Social relations ▶▶ Finances ▶▶ Legal and safety issues ▶▶ Work and school ▶▶ Health ▶▶ Cultural components ▶▶ Potential for exploitation The Clinical Pathway to Determine and Document Medical Necessity
Comprehensive Assessment
Clinical Formulation for Medical Necessity
Treatment Plan of Care includes goals/objectives based on Behaviors/ Symptoms that determined Medical Necessity
Document behavioral changes and progress towards goals/objectives based on Medical Necessity
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Section 3: Medical Necessity Medical Necessity Criteria for MHP Reimbursement of Specialty Mental Health Services. (excerpt from California Code of Regulations, Title 9, Article 2. Provision of Services §1830.205.) (A)
The following medical necessity criteria determine Medi-Cal reimbursement for specialty mental health services that are the responsibility of the MHP under this subchapter, except as specially provided. (B)
(C)
The beneficiary must meet criteria outlined in (1), (2), and (3) below to be eligible for services: (1) DSM-IV Disorder. Must have 1 of the following disorders: (a) Pervasive Developmental Disorders, except Autistic Disorders (b) Disruptive Behavior and Attention Deficit Disorders (c) Feeding and Eating Disorders of Infancy and Early Childhood (d) Elimination Disorders (e) Other Disorders of Infancy, Childhood, or Adolescence (f) Schizophrenia and other Psychotic Disorders (g) Mood Disorders (h) Anxiety Disorders (i) Somatoform Disorders (j) Factitious Disorders (k) Dissociative Disorders (l) Paraphilias (m) Gender Identity Disorder (n) Eating Disorders (o) Impulse Control Disorders Not Elsewhere Classified (p) Adjustment Disorders (q) Personality Disorders (except Anti-Social Personality) (r) Medication-Induced Movement Disorders related to other included diagnoses (2)
Impairment. Must have at least one of the following impairments as a result of the mental disorder(s) listed in subdivision (1) above: (a) A significant impairment in an important area of life functioning (b) A probability of significant deterioration in an important area of life functioning (c) Except as provided in Section 1830.210, a probability a child will not progress developmentally as individually appropriate. For the purposes of this section, a child is a person under 21 years of age.
(3)
Intervention. Must meet each of the intervention criteria listed below: (a) The focus of the proposed intervention is to address the condition identified in (2) above. (b) The expectation is that the proposed intervention will: 1. Significantly diminish the impairment, or 2. Prevent significant deterioration in an important area of life functioning, or 3. Except as provided in Section 1830.210, allow the child to progress developmentally as individually appropriate. (c) The condition would not be responsive to physical health care based treatment.
When the requirements of this section are met, benefici ries shall receive specialty mental health services for a diagnosis included in subsection (b)(1) even if a diagnosis that is not included in subsection (b)(1) is also present.
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Section 3: Medical Necessity NOTE: The i pairment and impact on functioning which is the focus of attention, must be a result of symptoms that are clearly related to the included diagnosis in the most current DSM, to qualify for service. You must show this connection through your documentation. Medical Necessity Criteria For MHP Reimbursement For Specialty Mental Health Services For Eligible Beneficiaries Under 21 Years Of Age (California Code of Regulations, Title 9, Article 2. Provision of Services §1830.215) (a) For beneficiaries under 21 years of age who do not meet the medical necessity requirements of Section 1830.205(b)(2) and (3), medical necessity criteria for specialty mental health services covered by this subchapter shall be met when all the following exist: 1. The beneficiary meets the diagnosis criteria in Section 1830.205(b) (1). 2. The beneficiary has a condition that would not be responsive to physical health care based treatment, and 3. The requirements of Title 22, Section 51340(e)(3) are met; or, for targeted case management services the service to which access is to be gained through case management is medically necessary for the beneficiary under Section 1830.205 or under Title 22, Section 51340(e)(3) and the requirements of Title 22, Section 51340(f) are met.” Excluded Diagnoses (these CANNOT be primary, but may be secondary diagnoses): ▶▶ Mental Retardation ▶▶ Learning Disorders ▶▶ Motor Skills Disorder ▶▶ Communication Disorders ▶▶ Autistic Disorder (other Pervasive Developmental Disorders are included) ▶▶ Tic Disorders ▶▶ Delirium, Dementia, and Amnestic and Other Cognitive Disorders ▶▶ Mental Disorders Due to a General Medical Condition ▶▶ Substance-Related Disorders (including tobacco use/ smoking cessation) ▶▶ Sexual Dysfunctions ▶▶ Sleep Disorders ▶▶ Antisocial Personality Disorder ▶▶ Other Conditions that may be a focus of clinical attention, except Medication Induced Movement Disorders, which are included
Clients may receive services for an excluded diagnosis, Only if, an included diagnosis is also present... And, the included diagnosis is the principle focus of treatment.
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Section 4: Specialty Mental Health Services What does Specialty Mental Health Services mean? Specialty mental health services are services provided to individuals whose mental health care needs cannot be treated effectively by their primary care physician. SPECIALTY MENTAL HEALTH SERVICES -- CCR Title 9, Division 1 §1810.247. “Specialty Mental Health Services” means: (a) Rehabilitative Services, which includes: 1. Mental Health Services, 2. Medication Support Services, 3. Day Treatment Intensive, 4. Day Rehabilitation, 5. Crisis Intervention, 6. Crisis Stabilization, 7. Adult Residential Treatment Services, 8. Crisis Residential Services, and 9. Psychiatric Health Facility services. (b) Psychiatric Inpatient Hospital Services; (c) Targeted Case Management; (d) Psychiatrist Services; (e) Psychological Services; (f) Early Periodic Screening, Diagnosis Treatment (Supplemental Specialty Mental Health Services); and (g) Psychiatric Nursing Facility Services Mental Health Services, CCR Title 9, Division 1 §1810.227. Mental Health Services mean those individual or group therapies and interventions that are designed to provide reduction of mental disability and improvement or maintenance of functioning consistent with the goals of learning, development, independent living and enhanced self-sufficiency and that are not provided as a component of adult residential services, crisis residential treatment services, crisis intervention, crisis stabilization, day rehabilitation, or day treatment intensive. Service activities may include but are not limited to assessment, plan development, therapy, rehabilitation and collateral.
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Section 4: Specialty Mental Health Services Definitions for Specialty Mental Health Services Adult Residential: Rehabilitation services provided in a non institutional setting that supports the client to restore, maintain and apply interpersonal and independent living skills and access community support systems. Services are structured and available 24-hours a day, 7-days a week. Assessment: Evaluation/analysis of client’s historic and current mental, emotional, and/or behavioral disorders. Review of any relevant family, cultural, medical, substance abuse, legal or other complicating factors. Establishes the diagnosis and may include the use of testing procedures.The mental status examination, diagnosis, psychological testing, and clinical formulation must be completed by a clinician consistent with his/her scope of practice. Other Assessments: TBS Assessment is the Intial Assessment of a child referred for TBS services. Case Management: Case Management services are activities provided by program staff that assist the client in being able to access medical, educational, social, prevocational, vocational, rehabilitative, or other community services and treatment. Inter and Intra agency communication, coordination and monitoring regarding appointments/forms. Linkage to transportation, housing or finance services may be provided. Also includes discharge planning and placement services to assist the client in securing an adequate living environment. Includes placement from institutional, hospital facilities within 30 days of discharge. Collateral: Collateral services include consultation and training of the significant support person to assist in better utilization of services and in understanding of the client’s serious mental health issues. The intent of collateral services are to help the significant support person be able to improve the client’s mental health status so that plan of care goals can be met. Collateral services help the significant support person to understand and accept the client’s condition and involve them in treatment service planning and in the implementation of the client plan. Collateral is billed when the support person can work “with” the client around the client plan as a result of the collateral contact. Significant support person may be family members, roommates and excludes contacts with other professionals. Crisis Intervention: Crisis Intervention is an unplanned event that results in the client’s need for a quick emergency response and requires immediate intervention to enable the individual to cope with the crisis while maintaining his/her status as a functioning community member. If the crisis is not treated, the client may present as an imminent threat to self or others. Crisis Intervention lasts less than 24 hours, clients experiencing acute psychological distress, acute suicidal ideation or inability to care for themselves due to a mental disorder are examples. Services are face to face or by phone with the client/significant support person, may be provided in the office or community. May include assessment of the crisis, therapy to stabilize the crisis and/or collateral when providing counseling to a support person. Crisis Stabilization: means a service lasting less than 24 hours, to or on behalf of a beneficiary for a condition which requires more timely response than a regularly scheduled visit. Service activities may include but are not limited to assessment, collateral and therapy. Crisis stabilization must be provided on site at a 24-hour health facility or hospital-based outpatient program or at other provider sites which have been certified by the department, or a Mental Health Plan to provide crisis stabilization services. Day Rehabilitation: Structured program of rehabilitation and therapy, to improve, maintain or restore personal independence and functioning consistent withlearning and development. Focuses on maintaining individuals in the community and /or school and may be integrated with an education program. Must be pre-authorized. Day Treatment Intensive: Structured multi-disciplinary treatment program as alternative to hospitalization, to avoid placement in a more restrictive setting or to maintain a client in a community setting. Provides a range of services to assist in gaining social and functional skills necessary for appropriate development and social integration and may be integrated with an educational program. Must be pre-authorized.
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Section 4: Specialty Mental Health Services Definitions for Specialty Mental Health Services (Continued) Family Therapy: Therapy directed toward the family system in which the client is present with at least one or more family members or significant support persons. Family Therapy can be provided only by clinicians consistent with their scope of practice.
Group Therapy: Group Therapy provides a psychodynamic, evidenced-based approach on topics such as depression, anxiety disorder, interpersonal relationship, etc., used whenever service is provided to more than one client in a group setting. May be provided by more than one clinician who must be eligible to bill for the type of group service being provided. Each group focus may have a specific service code, for example, a welcome group would be coded as a rehab group and could be provided by any clinician, but a medication group to discuss sideeffects of medications may only be provided by medically licensed staff such as, Physicians, Pharmacists, Nurse Practitioners, Registered Nurses, Licensed Vocational Nurse/Licensed Psychiatric Technicians, if it is within their scope of practice. Types of “groups” include: Collateral, Rehabilitation, Multi-family, Medication, Psychotherapy groups. Indvidual Therapy: a service activity that employs a therapeutic intervention to treat cognitive, behavior, interpersonal and psychological problems. Therapeutic interventions are consistent with client’s goals and which focus primarily on symptom reduction in order to improve functioning. Individual Therapy uses a psychodynamic foundation which includes discussion, assignments, client’s response and progress. Individual Therapy can be provided only by clinicians consistent with their scope of practice. Medication Services: Services that include prescribing, administering, dispensing and monitoring of psychiatric medications necessary to alleviate the symptoms of mental illness. Evaluating the need for medication, the clinical effectivenss, side effects, obtaining informed consent, ordering related blood work, medication education, plan development related to medication services are provided consistent with practitioner’s scope of practice. Plan Development: Development of client plan, approval of a client plan, monitoring the client’s progresss toward goal accomplishment, evaluating if the plan needs modification, consultation/collaboration with mental health staff/other professionals involved in the client’s treatment plan to assist, develop or modify the plan. Can include development of client’s therapeutic contracts, coordinating goals with the client, and how to meet these goals, and planning, arranging and reviewing assignments with the client. Can be used as clinically indicated, whenever the client status changes and there is a need to update the treatment plan. Psychological Testing: Means the use of one or more standardized measurement instruments, devices, or procedures including the use of computerized psychological tests, to observe or record human behavior, and which require the application of appropriate normative data for interpretation or classification and includes the use of standardized instruments for the purpose of the diagnosis and treatment of mental and emotional disorders and disabilities, the evaluation or assessment of cognitive or intellectual abilities, personality and emotional states and traits, and neuropsychological functioning. Psychological tests may only be performed by qualified staff within their scope of practice and can be part of an “assessment.” Rehabilitation: Working with a client to develop skills that maintain and/or restore optimal functioning. Providing education/training to assist the client to achieve his/her personal goals in such areas of daily living skills, socialization, grooming and personal hygiene, meal preparation, mood stabilization, resource utilization and medication compliance. Assistance to assess housing needs and to obtain and maintain a satisfactory living arrangement. Therapeutic Behavioral Services (TBS): One to one therapeutic contacts between a mental health provider and client for a specified period of time designed to maintain residential placement and prevent out of home placement at the lowest appropriate level by resolving target behaviors and achieving short term goals. TBS is not a “stand alone” service and must include another Mental Health Service.
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Section 4: How to Document Specialty Mental Health Services You will be able to understand “how to” document, code and bill for each Specialty Mental Health Service in the following sections of this manual.
The diagram below represents the Treatment Cycle of Providing Specialty Mental Health Services.
Assessment Financial Eligibility
Medical Necessity
Update Plan of Care
Plan of Care
Re-Assess/ Re-Evaluate
Service Provided
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Section 5: Treatment Documentation A. Assessment Assessment, CCR Title 9, Division 1 §1810.204. Assessment is a service activity which may include a clinical analysis of the history and current status of an Individual’s mental, emotional, or behavioral disorder; relevant cultural issues and history; diagnosis; and the use of testing procedures.
Elements of an Initial Assessment1 The following has been taken directly from the CCR, Title 9’s contract with MHPs. Although the State does not require the use of a specific assessment form, SFDPH, Community Programs requires that providers use SFDPH, Community Programs Avatar Assessment Forms. The following areas shall be included as appropriate as a part of a comprehensive client record. ➢➢ Relevant physical health conditions reported by the client shall be prominently identified and updated as appropriate. ➢➢ Presenting problems and relevant conditions affecting the client’s physical health and mental health status shall be documented, for example: living situation, daily activities, and social support. ➢➢ Documentation shall describe client strengths in achieving client plan goals. ➢➢ Special status situations that present a risk to client or others shall be prominently documented and updated as appropriate. ➢➢ Documentation shall include medications that have been prescribed by mental health plan physicians, dosages of each medication, dates of initial prescriptions and refills, and documentation of informed consent for medications. ➢➢ Client self report of allergies and adverse reactions to medications, or lack of known allergies/sensitivities shall be clearly documented. ➢➢ A mental health history shall be documented, including: previous treatment dates, providers, therapeutic interventions and responses, sources of clinical data, relevant family information and relevant results of relevant lab tests and consultation reports. ➢➢ For children and adolescents, pre-natal and perinatal events and complete developmental history shall be documented. ➢➢ Documentation shall include past and present use of tobacco, alcohol, and caffeine, as well as illicit, prescribed and over-thecounter drugs. ➢➢ A relevant mental status examination shall be documented. ➢➢ A five-axis diagnosis from the most current DSM, or a diagnosis from the most current ICD (International Classification of Diseases), shall be documented, consistent with the presenting problems, history, mental status evaluation and /or other assessment. 1
Note: All sections of the assessment must be completed. DO NOT LEAVE any section blank. If not applicable, document “N/A or Unknown.”
Excerpt from DHCS’s “MHP Contract” with City/County of San Francisco
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Section 5: Treatment Documentation Diagnostic Formulation
A comprehensive assessment of a client’s functioning, living situation, history of physical, emotional, social and psychological functioning will also lead to the most accurate diagnostic formulation. A good diagnostic formulation supports compliance with Medicare, Medi-Cal and other third party payor regulations by documenting behavior and psychological impairments that significantly impair social and psychological function and substantiates medical necessity. In formulating the diagnosis, be aware of the following: ➢➢Axis I must have the primary diagnosis name and code. (for included and excluded diagnosis Click Here) ➢➢If there is no Axis II or Axis III diagnosis, use V71.09 (code for no diagnosis) or 799.9 (code for diagnosis deferred). ➢➢The following CANNOT be used for a primary/prinicipal diagnosis when billing planned mental health services (Medi-Cal/Medicare): 1. V-codes 2. Deferred codes 3. Rule-outs 4. Excluded diagnoses EXCEPTION: A V-code or deferred code may be used temporarily while completing the client’s Assessment. However, ONLY Assessment, Plan Development and Crisis Intervention services can be billed prior to the completion of the Plan of Care and determining an included diagnosis for Medical Necessity. Table 1: Assessment/Evaluations, Scope of Practice and Frequency
Staff Type (Scope)
CANS ANSA Crisis Intial Initial Assessment Assessment Assessment
Physician Psychiatric Evaluation
Re-Assessment Psychological Assessment Testing Updates Check Program at least Annually
30 days
60 days
As Indicated
60 days
X X
X X
X X
X
PhD/PsyD/EdD/ MFT/LCSW/Registered/Waivered staff
X
X
X
X
MHRS**
X
X
X
X
All Others** (supevised by LPHA)
X
X
MD/DO/RN* RN/LVN/LPT**
As Indicated
X X X
(within scope)
X
* RN’s who are Clinical Nurse Specialists, Nurse Practitioners or possess a Master’s Degree in Psychology **These staff may not determine diagnoses, but may assist in completion of the assessment. Plans of Care must be co-signed by LPHA. For more information regarding qualifications and privileges Click Here
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Section 5: Treatment Documentation Coding, Documenting And Billing For Assessment Services • • • •
You will document your services using the Avatar Electronic Health Record. You will select the correct assessment documents for the type of assessment you are providing. Any service you provide, document, code and bill must be a service that your program is authorized to provide. Any service you provide must be within your professional scope of practice.
You must have an admission diagnosis selection in Avatar. The primary/principal diagnosis (which is the focus of treatment) must be an “included” diagnosis for Medi-Cal/Medicare planned Specialty Mental Health Services. This included diagnosis can be a pre-existing, historical, or other included diagnosis. To establish medical necessity, both excluded and included diagnosis can be claimed for crisis services and the initial assessment. The progress note examples are to show a comprehensive narrative note that meets criteria for the service code. Location/Duration and other drop down selections that Avatar uses are NOT present in these sample notes.
90801- Psychiatric Diagnostic Interview Examination This code is used to bill for the face-to-face assessment of a client by CPT Users (licensed, registered or waived staff). If it requires more than one session to complete the assessment, document the need for additional sessions in a progress note. A psychiatrist and a clinician may both complete an assessment and use this code for the same client when completing assessment documents. (If an MD/DO/NP is doing only a limited assessment designed to prescribe medications, s/he may use 90862 – see Medication Section for details). Examples include: Initial Assessment by Clinician/Psychiatrist; Annual Assessment Update; Re-Assessment for a client who has returned to treatment. If the initial assessment is completed by another clinician, then MD/DO/NP must use med support service codes.
Sample Note for 90801- MEDI-CAL/MEDICARE CLIENTS- Completed Assessment after Session (same day) 90801 8/31/11 This writer met with client and parent for an initial psychiatric assessment. Reviewed presenting problems, and obtained client’s developmental, family, social, educational and mental health history. See CYF CANS Assessment for full description. RTC 9/15/11 4pm-------------------------------------------------- Sara Staff, LCSW
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Section 5: Treatment Documentation Sample Note for 90801- MEDI-CAL /MEDICARE CHILD CLIENT Incomplete Assessment need follow-up Session 90801 8/31/11 This writer met with client and parent for an initial psychiatric assessment. Reviewed presenting problems, and obtained client’s developmental, family and social history. Attempted to complete the assessment today, but we were unable to complete full assessment due to client’s short attention span. Will meet next week to continue the assessment. RTC 9/15/11 4:15pm-------------------------------------------------------Quintin Staff, MFT
Sample Note for 90801- MEDI-CAL/MEDICARE ADULT CLIENTS Completed Assessment after Session (same day) 90801 8/20/11 This clinician met with client for an initial psychiatric assessment. Reviewed presenting problems, and obtained family, social, medical, substance use and mental health history. See assessment dated 8/20/11 for full description. RTC 9/15/11 10am. The plan is to work with the client to develop treatment goals and objectives----------------------------------------------------------------------------------------------------------- Pat Staff, LCSW
Sample Note for 90801- MEDI-CAL/MEDICARE CLIENTS Assessment completed on a different day than initial session 90801 Multiple 8/20/11 This writer met with the client for an initial psychiatric evaluation. Reviewed client’s presenting problems; obtained family, social and medical history. Will continue with assessment next session. RTC 8/30/2011 9am.----------------------------------------------------------------------------Ying Mae Staff, LCSW 8/30/11 The client reported to the clinic as scheduled. Completed intake assessment. For full description, please see assessment dated 8/30/11. The plan is to work with the client on TPOC next session. RTC 9/15/11------------------------------------------- ------------------------------------------------ Ying Mae Staff, LCSW
H2015AS – Assessment for HCPCS USERS This code is used for Assessment services provided by any of the following: unlicensed, non-registered, nonwaived staff, LVN, LPT, OTR, and RNs, or when services do not fall into a CPT category. These staff may not determine diagnoses, but may assist in completion of the assessment. Examples include: A non-licensed staff person completes all of the Assessment except the diagnostic formulation; An RN meets with a client for an initial assessment meeting and completes the assessment (except for diagnosis).
A Collaborative Assessment When one starts the assessment with a choice; asking clients whether they’d like to talk about strengths or current concerns. Clients generally prefer you to use open, direct conversation to talk about functioning, concerns, and talking about sensitive aspects of functioning and development, including substance use, sexual development/functioning, and spirituality.
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Section 5: Treatment Documentation 90802 – Interactive Psychiatric Diagnostic Interview Examination The Interactive Examination (90802) is the same as 90801 but includes interactive techniques. This interview involves the use of physical aids and non-verbal communication to overcome barriers to therapeutic action between the clinician and the client who has not yet developed, or has lost, either the expressive language communication skills to understand the clinician if s/he were to use ordinary language for communication. These activities could include but are not limited to art, hand-puppets, sand trays, TDD machines, sign language interpreter, language interpreter. Examples include: Assessment of monolingual client; Assessment of deaf client; Assessment of child who has not developed expressive language communication skills; Assessment of client whose communication skills have been affected by traumatic event. Sample Note for 90802- Medi-Cal /Medicare Client: Interactive Activities 90802 8/16/11 This clinician met with client and parent for an initial psychiatric assessment. Due to parent being monolingual in Mandarin, an interpreter was used - Wei An Staff from Asian American MH. We reviewed the current presenting problems and symptoms; obtained developmental, social, family, substance use and mental health history. For further information, please see CYF CANS Assessment dated 8/16/11. RTC on 8/30/11 5pm, to discuss TPOC goals and objectives. ------------------------------------------------------------------------------------------------------William Staff, LCSW
Moving from Assessment Review to Treatment Planning Clients and significant support persons alike expressed concerns that assessments be translated into meaningful action to improve their life. Participants stated that they wanted clear, behavioral strategies to try to improve interactions and functioning. Clients and significant support persons need to be able to try new behaviors you have provided, and to have a treatment plan written in their language to be sure that they know their goals and behaviors/strategies for meeting those goals.
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Section 5: Treatment Documentation 96100 Psychological Testing- Central Nervous System Assessment/Testing This CPT code includes psychodiagnostic assessment of personality, psychopathology, emotionality, intellectual abilities (e.g., WAIS-R, Rorschach, MMPI) with interpretation and report. ▶▶ Note: The psychological testing report might be completed on a different day than administration of the test(s), but this code is still used. When requesting or administering a psychological test, the therapist must document in a progress note his/her rationale/justification for the psychological test. Examples include: Psychologist completes full battery of tests at the request of the child’s primary therapist; Neuropsychologist completes report. Sample Note for 96100- Medi-Cal/Medicare Clients: Psychological Testing 96100 8/15/11 Multiple Administered and completed WAIS-R and Rorschach with the client. Throughout testing, the client presented with poor concentration and required periodic short breaks. She reported feeling tired and appeared agitated and annoyed about having to complete the testing. The client required repeated prompting and encouragement to complete the task. The plan is to administer additional testing instruments (Note: name all the tests you plan to administer) on 8/17/11. See psychological testing report for full information regarding scoring and interpretation..................................... Ravi Staff, PsyD 96100 8/17/11 The client reported to the clinic as scheduled to continue with the psychological testing process. The client appeared in good spirits and eager to begin testing. Administered and completed the remaining test battery (Note: name all the tests you administered on this date). The client required periodic breaks due to difficulty with concentration, but she maintained a positive attitude throughout testing. Plan is to score, interpret and write up a report. Once completed, this examiner will review findings with client and her primary therapist…………….........................................……..................…….. Ravi Staff, PsyD 96100 8/30/11 Completed psychological testing report (see report dated 8/30/11). The plan is to review findings with the client and her primary therapist next week…………........................…………..….……. Ravi Staff, PsyD
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Section 5: Treatment Documentation
B. Treatment Plan of Care
Billing: Client Plan Development, CCR Title 9, Division 1 §1810.232. “Plan Development means a service activity which consists of development of client plans, approval of client plans, and/or monitoring of a beneficiary’s progress.” State Department of Healthcare Services (DHCS) requires that: ➢➢ The client’s Treatment Plan of Care outlines the goals, objectives, interventions and timeframes for diminishing or preventing deterioration of the impairment(s) that has been identified through the assessment process and your clinical formulation. It must substantiate on-going medical necessity and must be consistent with the diagnosis that is the focus of mental health treatment. Strength-based and recovery oriented treatment planning is strongly encouraged. ➢➢ Client signature on the plan shall be used as the means by which the MHP documents the participation of the client. ➢➢ The Treatment Plan of Care is completed prior to the delivery of planned services and is completed no later than 60 days from the start of service, and no less than annually there after. ➢➢ The MHP shall give a copy of the client plan to the client on request.
Key Points of Treatment Plan of Care Documentation
1. Focus of Treatment (Medi-Cal Regulations – Medical Necessity Criteria) • Objectives/Interventions must focus on IMPAIRMENTS which are related to an Included Diagnosis. 2. The Client’s Goals (W&I Code Sec. 5600.2) • The client is “the central and deciding figure in all planning for treatment,” except where specifically limited by law. 3. Objectives must be specific, observable or measurable (Medi-Cal Regulations and CCR, Title 9 Contract) • The plan of care must contain goals or objectives which are specific and observable or measurable. 4. Progress Toward Goals (CCR, Title 9 Contract) • Progress notes must contain interventions, client response to interventions, client progress toward treatment plan goals/objectives, other relevant assessment information and clinical decisions.
GOALS Goals should be general and broad, and address the symptoms/behaviors and risk areas that are outlined in the assessment. The client’s goals should also be included on the treatment plan of care as clients should be central in planning for their treatment. The plan of care includes an area where the client can state their goals in their own words. This should include the client’s desired outcome of treatment and include their interests and intent such as, returning to work or graduating from high school. These goals have a special place in a recovery-oriented system, and should speak to the client’s ability to manage or recover from his/her illness and achieve developmental milestones.
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Section 5: Treatment Documentation Goals… are broad, long-term aims. ▶▶ Should refer to the ultimate purpose or purposes of the service ▶▶ Should be clearly related to medical necessity criteria related to significant areas of life functioning ▶▶ Could take years to accomplish for a person with a serious, persistent mental illness ▶▶ Would require the accomplishment of several or many Objectives ▶▶ Address the symptoms/behaviors and risk areas that are outlined in the assessment.
OBJECTIVES
Objectives must be specific and observable or measurable and stated in terms of the specific impairment in functioning areas (such as living situation, activities of daily living, school, work, social support, legal issues, safety physical health, substance abuse and psychiatric symptoms) that are identified in the assessment, diagnosis and clinical formulation of medical necessity.
Research studies have shown that when staff and client are clear (especially on goal consensus), outcomes are more effective than when they are not clear about expectation of treatment and goals/objectives.
Objectives are concrete attainments that can be achieved by following a certain number of steps. ▶▶ Objectives are the steps that get you to the Goal ▶▶ Specific enough to achieve a high degree of inter-provider agreement. reliability ▶▶ Observable and/or measurable and quantifiable ▶▶ Achievable in a timeframe that is realistic and meaningful to the client ▶▶ Clear enough that the client can effectively direct effort toward their achievement
INTERVENTIONS Interventions are the steps the practitioners will take in order to assist the client to meet his/her objectives and eventually the life goal. Interventions must be consistent with the mental health goals/objectives and must meet the medical necessity requirements that the proposed intervention(s) will have a positive impact on the identified impairments. Examples of Interventions include: • Offer stress reduction techniques to reduce anxiety attending weekly group therapy sessions for the next three months. • Support client to express unresolved grief to reduce symptoms of depression in bi-weekly individual sessions for the next six months. In addition to the client’s goals and objectives being developed in relationship to the diagnosis, it is essential that the interventions and timeframes outlined in the Treatment Plan truly reflect what you, the provider will do. NOTE: The interventions in the progress note need to be more specific. Examples: 1. Address anxiety by identifying triggers, or keeping a journal and practicing techniques for anxiety reduction. 2. Address parent/child relationship and mother’s ability to set appropriate limits by role modeling, problemsolving situations that arise at home, and teaching alternative parenting techniques.
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Section 5: Treatment Documentation cont.
GOAL
OBJECTIVE
INTERVENTION
Decrease Psychosis
Decrease psychotic symptoms as noted by improved self-care, decreased suspiciousness and reduction in auditory hallucinations as reported by ct and family.
Psychiatric evaluation/med support services. Client & family education re:diagnosis & med compliance issues. Develop plan to address early warning signs of relapse (e.g., med non-compliance, program nonattendance, change in mental status). Indiv. and/or family therapy 1X /wk.
Obtain Housing
Obtain safe and secure housing to stabilize ct’s paranoia and anxiety and diabetes to ensure ct’s health, safety and wellbeing.
Case management and/or individual sessions to assist client in completing applications for housing and/ or board and care programs and to monitor client status.
Decrease Depression
Client will decrease sxs of depression such as hopelessness, worthlessness and isolation by doing one of his identified enjoyable activities (e.g., swimming, attend AA mtgs and church, play piano, walk in park) at least 4X/wk per ct report and journal entry.
Review feelings of depression, coping skills and journal of enjoyable activities in biweekly individual and/or group sessions.
Decrease Substance Abuse
Client will reduce/abstain from alcohol abuse by acknowledging its negative effects on his Individual and group therapy and life including loss of family, case management to support cleint’s violent street fights, and incar- plan for sobriety from alcohol. ceration and will attend AA meetings at least 4X/wk.
Note: The Client’s Goals should also be included on the Treatment Plan of Care (TPOC) as clients should be central in planning for their treatment and recovery. The TPOC has an area for the client’ stated goal(s) in their own words. This should include the client’s desired outcome of treatment and include their interests and intent such as returning to work or graduating from high school. These goals have a special place in a recovery oriented system, and should speak to the client’s ability to manage or recover from his/ her illness and achieve major developmental milestones.
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Section 5: Treatment Documentation cont.
Timelines/Frequency of the Client Treatment Plan of Care: • The initial treatment plan shall be completed no later than 60 days of the episode opening. • Shall be updated at least annually or as needed based on changes in client’s status, diagnosis, assessment findings, and/or new developments. Note: medication support services clients also require a Treatment Plan of Care (TPOC). “Meds Only” TPOC is required at least annually and can include medication compliance goals. Medication progress notes must document the client’s medication plan goals, and address progress or lack of progress on these goals. Table 2: Treatment Plan of Care Timelines - General Type of Client Adult/Older Adult Child/Adolescent Day Rehab Day Treatment Intensive Child/Adolescent Intensive Case Mgmt. Meds Only
Who Can Complete POC?
Type of Plan of Care
When Due No Later than...
Frequency
Co-signed by LPHA, if not a LPHA?
All
Initial
60 Days
Annual
Yes
All
Initial
60 Days
Annual
Yes
All
On-going care plan
Every 6 months
Biennial
Yes
All
On-going care plan
Every 3 months
Quarterly
Yes
All
On-going care plan
60 Days (see CYF CANS)
See CYF guidelines
Yes
Physician/NP
Med Support
60 Days
Annual
No
Initial Treatment Plan: The Initial Treatment Plan of Care (TPOC) is to be completed no later than 60 days for Adults and Older Adults, child and youth, from the date of opening (which is CBHS’ allowed duration for the assessment period), or prior to the delivery of any “planned” mental health services (Individual, Group, Case Management, Medication Support, Collateral, etc.), whichever comes sooner. If there is no initial TPOC yet in place, only the following services can be claimed: Assessment, Crisis and Plan Development used only when writing the initial TPOC. Annual Renewal of TPOC: A new TPOC is required at least annually for ongoing clients. It is ideal to align the TPOC annual renewal date with the annual PURQC anniversary for the date of episode opening to keep annual documents synchronized for tracking purposes, but it is not absolutely necessary. Updates to the Plan: The TPOC must be updated any time there is a significant development or change in the focus of treatment. If this happens mid-year, the existing TPOC can be updated (by using the Treatment Plan Addendum feature in Avatar) by adding the new information and goal(s)/objective(s) with a date and client signature. If it is a major change, a new TPOC may be necessary. All Planned Services must be covered by a current and valid TPOC: In order to bill planned services, a TPOC, complete with client signature indicating client participation in the formulation of the plan, must be in place. If there is a lapse between TPOC expiration and renewal dates, then services occurring during the lapse cannot be billed, and will be disallowed. Therefore, it is important to be timely with the renewal of TPOCs. If a client’s signature cannot be obtained, the reason why it cannot be obtained, and continued subsequent efforts to obtain it, must be documented in the progress notes. For issued memorandum Click Here.
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Section 5: Treatment Documentation cont. Signatures and Dates: The Treatment Plan of Care must be signed by the client and the program staff member completing the Treatment Plan; a minor can sign the Plan of Care as well. It is encouraged that a parent/guardian (i.e., DHS worker, conservator, etc.) signature is obtained whenever possible. 1. Clinicians are strongly encouraged to obtain the client and parent/guardian’s signature to ensure participation in the Treatment Plan. 2. For youth treated under minor consent law, the youth MUST sign the Treatment Plan of Care the same requirement as adults. 3. Program staff must also sign the Plan of Care. 4. A co-signature of a Licensed Practitioner of the Healing Arts (LPHA) is needed when the staff member completing the Treatment Plan of Care is not licensed/registered/waived. 5. If a client or parent/guardian refuses to sign or is unavailable to sign, the clinician completes a progress note documenting the reason that the parent/guardian signature was not obtained in a timely manner. Continue to document subsequent attempts to obtain a signature in progress notes, especially for the following reasons: ➢➢ ➢➢ ➢➢ ➢➢ 6.
should document phone contact(s) or letters (keep a copy in the chart under “correspondance”) should document when the therapist discusses the Treatment Plan of Care goals over the phone when the parent/guardian accepts/agrees to the Treatment Plan of Care goals. should document when a copy of the Treatment Plan of Care is mailed to parent/guardian for a signature along with any follow-up until the sign copy is received and filed. ongoing attempt must be made to obtain client’s signature throughout the course of treatment
The Treatment Plan of Care is now an electronic document through the Avatar electronic health record system. Participation by the client, parent/guardian is captured by requiring the clinician to select if the client signed the plan and if not, if there was verbal approval or, if there is a refusal to explain in the comment section of the plan why the signature(s) is missing. The clinician is unable to exit the Treatment Plan of Care if these required fields are not completed.
7. In addition to participation through client signature on the Treatment Plan of Care, this Avatar document requires the clinician to offer and provide a copy of the Treatment Plan of Care to the client. This field is required and the clinician will be unable to exit the Treatment Plan of Care if these fields are not completed. For additional information regarding the Avatar instruction manual and user guide, please visit: www.sfdph.org
Reviewing Treatment Progress and Goals Clients and significant support persons stated that they would like frequent check-ins around their use of specific treatment strategies, and formal review of treatment progress every few months. You should set this expectation as the clinician. Participants agreed that they want clear behavioral strategies to try to improve symptoms and functioning. If these new behaviors aren’t working, they need the clinician to be able to provide new, effective methods of intervention to reach stated goals. The clinician should also be open to the possibility that a new clinician may be necessary to better address the needs of the client or significant support person.
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Section 5: Treatment Documentation cont. Treatment Plan of Care: CYF and CANS** ▶▶ In the Children’s system, the CANS “items” are the treatment “Goals.” ▶▶ When CANS assessment rates behavior/condition items at a “2 or 3,” the behavior/condition requires an intervention and must be addressed in the Treatment Plan of Care. ▶▶ The specific Objectives stemming from those Goals must be observable, measurable, concrete, and use the caregiver and youth’s language. ▶▶ Objectives may target specific behaviors or symptoms for change, or build new skills or behaviors to replace behaviors which are unproductive or troubling. ▶▶ The CANS Treatment Plan Library in Avatar contains examples of how to write Objectives which will meet Medi-Cal audit critieria. ▶▶ These Objectives, when used, need to be tailored to your client’s specific needs and strengths. ▶▶ All Treatment Plans are due no later than 60 days from the date of opening Table 3. CANS / MH Assessment and Treatment Plan of Care (TPOC) Frequency Guidelines Level of Care
Outpatient
Intensive Outpatient
Day Treatment
Initial Assessment and Treatment Plan Within 30 Business Days of Episode Opening Within 30 Business Days of Episode Opening
Within 30 Business Days of Episode Opening
First ReAssessment
First ReAssessment TPOC
Subsequent ReAssessments
Within 8 months (245 Within 8 months (245 Every 12 months Calendar Days) of Calendar Days) of thereafter (i.e., Episode Opening Episode Opening within 20 months of Episode Opening) Within 8 months (245 Within 8 months (245 Every 6 months Calendar Days) of Calendar Days) of thereafter (i.e., Episode Opening Episode Opening within 14 months of Episode Opening)
Within 3 months of Episode Opening
If Reassessment unchanged, retain original TPOC. If changes in Needs are identified, create new TPOC within 3 months of Episode Opening
Every 3 months thereafter (i.e., within 9 months of Episode Opening)
Subsequent TPOC Every 12 months thereafter (i.e., within 20 months of Episode Opening) Every 6 months thereafter (i.e., within 14 months of Episode Opening) If Reassessment is unchanged, TPOC should be every 6 month (I.e., at 6 months, 18 months). If at any point the Reassessment identifies changes in Needs, update TPOC
**Nate Israel, PhD, Office of Quality Management, SFDPH Co-occurring Disorders San Francisco, Community Programs consistently assesses and treat co-occurring disorders (including substance abuse/dependency, trauma related, and developmental disorders). The presence of a co-occurring disorder will not, in and of itself, trigger disallowance of specialty mental health Medi-Cal claiming. All diagnoses for mental illness and co-occurring disorders shall be documented in the chart when criteria are present. Co-occurring disorders maybe addressed in an intervention as it creates a barrier or obstacle in the treatment of the mental health disorder. Note: substance abuse can be a secondary diagnosis.
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Section 5: Treatment Documentation cont.
C. Documentation of Ongoing Services: Progress Notes For all services: You will document using the Avatar Electronic Health Record. ➢➢ You will select the correct service documents for the type of service you are providing. ➢➢ Any service you provide, document, code and bill must be a service that your program is authorized to provide. ➢➢ Any service you provide must be within your professional scope of practice. The progress note examples are to show a comprehensive narrative note that meets criteria for the service code. Location/Duration and other drop down selections that Avatar uses are NOT present in these sample notes.
1. Plan Development Plan Development, CCR Title 9, Division 1 §1810.232. “Plan Development means a service activity which consists of development of client plans, approval of client plans, and/or monitoring of a beneficiary’s progress.” H2015AP – Plan Development (Not claimed in Medicare, use for Medi-Cal claims ONLY) The Plan Development code is used by all disciplines when working on the following: 1. Writing the Plan of Care/Treatment Plan, 2. Updates to the Plan of Care, 3. Suggested changes to the Plan of Care, 4. Working directly with the client’s Plan of Care, 5. Plan Development is also used to bill for consultations, treatment meetings and case conferences for the purpose of developing, monitoring or changing the Treatment Plan of Care. Examples of Medi-Cal Plan Development claiming include: ▶▶ Reviewing previous documents in order to develop the Treatment Plan of Care; ▶▶ Writing the Treatment Plan of Care; ▶▶ Discussing the Treatment Plan of Care with a parent/guardian on the phone; ▶▶ Treatment meeting to discuss client progress on theTreatement Plan of Care; ▶▶ Consultation with another professional re: client’s treatment resulting in change to Plan of Care ▶▶ Meeting with client to discuss the Treatment Plan of Care and obtain client/caregiver signature as evidence of partcipation in the Plan of Care.
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Section 5: Treatment Documentation cont. Plan Development: Consultation All consultation services are billed using the HCPCS code for Plan Development, H2015AP. CPT codes should not be billed for these services. Consultation involves getting advice from another professional regarding the treatment needs of the client.
Consultation versus Supervision Supervision is an ongoing process during which the focus of the discussion is on enhancing the supervisee’s skills and managing workload, caseload, schedule. etc. If a discussion between a supervisor and supervisee is primarily about how s/he might be more effective with a client (adjust, change, improve his/her therapeutic techniques), this is considered supervision, NOT consultation, and therefore is not billable. Billable Consultation is a conversation initiated by a professional in order to use another professional’s specific expertise in determining or providing expertise to another professional on how to most effectively address the treatment needs of a client. The focus of the conversation is on the client’s plan of care. This is provided on an “as needed” basis, rather than during a regularly scheduled meeting, which also helps to distinguish consultation from supervision. Billable consultation is to address the treatment needs of a specific client, with an open case, to remove barriers to their mental health. Non-Billable Consultation is a conversation in which one person uses another’s expertise in a manner that is not focused on specific client’s need (e.g., this might occur when providing or receiving consultation about a group of clients or about principles relevant to clients in general). This is “educational” and “self-enlightenment” rather than consultation and is not billable.
Documentation of Consultation When documenting billable consultation, six (6) elements should be included in each progress note: 1. The reason for the consultation (establish medical necessity) 2. With whom did you speak? 3. What is the topic of the consultation (client’s condition)? 4. What plan is developed out of the consultation? 5. What consultant told you or recommended? 6. What is your intervention?
Sample Billable Consultation Progress Note H2015AP
01/30/12 20 min total time
I contacted client’s PCP provider, Joe Borne (415-411-9111) at Castro Mission Health Center requesting consult regarding shared client’s anorexia treatment plan of care. Client is obsessively focused and overly anxious regarding weight gain. Dr. Borne recommended how to redirect plan from weight focus to “health” focus. Will update plan to include the client to turn away from scale (her back to digital read-out) when being monitored for weight gain. Client to be enrolled in dietary health program.-------------------Ravi Staff, PsyD
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Section 5: Treatment Documentation 2. Individual Therapy Individual Therapy, CCR Title 9, Division 1 §1810.250 “Therapy”: Individual or Group means a service activity which is a therapeutic intervention that focuses primarily on symptom reduction as a means to improve functional impairments. Therapy may be delivered to an individual or group of beneficiaries and may include family therapy at which the beneficiary is present. “Rehabilitation”: Individual or Group means a service activity which includes assistance in restoring, improving, and/or maintaining a beneficiary’s or group of beneficiaries functional skills, daily living skills, social and leisure skills, grooming and personal hygeine skills, meal preparation skills, and support resources; and/or medication education. Examples include: Regularly scheduled individual psychotherapy sessions; Unscheduled individual session that does not meet criteria for crisis intervention. Codes Used in Individual Therapy and Rehabilitation CPT Codes Used Individual Therapy and Rehabilitation 90804 - Individual Therapy 20-44 Minutes 90806 - Individual Therapy 45-74 Minutes 90810 - Interactive Individual Therapy 20-44 Mins. 90812 - Interactive Individual Therapy 45-74 Mins
HCPCS Codes Used Individual Therapy and Rehabilitation H2015IT- Individual Rehabilitation
Sample Note for 90806- Medi-Cal Client: Individual Psychotherapy 45- 74 mins. 90806 5/15/12 64 mins This writer met with client today to explore his overwhelming feelings of anxiety whenever he approaches the Bay Bridge. Client’s states he is paralyzed by fear and is unable to work in Oakland due to this debilitating fear of crossing the Bay Bridge. Client reports he was formerly able to control his emotions until he was involved in a recent non-injurious accident while crossing the Bay Bridge. Worked with client on how to use progressive relaxation techniques and visualizing himself crossing the Bay Bridge. Client was able to talk through his anxiety during this session. Plan is to continue to assist client in using relaxation and visualization to overcome feelings of dread and anxiety associated with the Bay Bridge. RTC 5/30/12 at 8am. ----------------------------------------------------------------------------------------------------------- Ravi Staff, PsyD
Important: “Medical Record Cloning" occurs when a progress note (individual, group, etc) is worded exactly like or similar to previous entries, which is considered a misrepresentation of the medical necessity requirement for coverage of services. State of California considers this a FRAUD!!
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Section 5: Treatment Documentation cont. H2015IT – Individual Rehabilitation This code is used for services provided by the following staff: RN, OTR, LPT, LVN, unlicensed, non-registered or non-waived staff members when providing individual rehabilitative services. This service code can be used in any location in the community, including school. Sample Note for H2015 IT Individual Rehabilitation H2015 IT 4/15/12 50 min face-to-face Met with client at his home residence. Client shared his progress in the treatment of his anxiety and depression by showing me his personal improvement chart noting the number of days client was able to use his deep breathing exercises with self-affirmation statements. Client states he is still experiencing difficulty sleeping at night stating he cannot fall asleep. Worked with client in examining his nightly routine which included drinking cola while watching the late night show. Educated client about caffeine products that will keep him awake and adopting a new sleep routine to turn off the TV at 9pm, darkening his bedroom and practicing progressive relaxation techniques and deep breathing when lying down. Client agreed to track his progress for next two weeks. Plan is to check in with client in two weeks and review his progress.------- Shar Staff, MHRS
Interactive Therapy Codes:
Interactive psychotherapy involves the use of physical aids and non-verbal communication to overcome barriers to therapeutic interaction between the clinician and a client who has not yet developed, or has lost, either the expressive language communication skills to explain her/her symptoms and response to treatment, or the receptive communication skills to understand the clinician if s/he were to use ordinary adult language for communication. Activities could include but are not limited to art, sand trays, TDD machines, sign language interpreter, language interpreter. Sample Note for 90812 Individual Psychotherapy Interactive CHILD Ro
90812 1/30/12 70 min total time A 12-year-old, Hispanic male treated for ADHD and anger management issues. Today, we used bataka sticks to interact. During course of play, Manny states he is upset with parents pending divorce. Manny taught how to redirect anger towards parents separation by using words to express feelings; encouraged and reinforced Manny to write down his negative thoughts and feelings, and to come up with an alternate solution. Roleplayed several scenarios in which Manny came up with an alternate solution to his angry outbursts. We utilized another interactive aid (bubble talk drawings) to engage him in treatment. Plan is for Manny to continue practicing his coping skills for the next two weeks. RTC 02/14/12 2:15pm------------------------------------------------------------------------------------------- Ravi Staff, PsyD
Sample Note for 90810 Individual Psychotherapy Interactive ADULT 90810 5/15/12 44 mins Met with a monolingual Spanish-speaking client in office with an interpreter (Ms. Rosario Staff). Today we focused on grief and loss issues regarding the gang shooting resulting in the death of her only son. Client continues to have nightmares and reports difficulty with sleeping and concentration which is interfering with her work and personal life. Provided support and empathy regarding her loss; encouraged client to continue her connecting with her family and her church for emotional and spiritual support. Problem solved with client on what she can do to address her sleep disturbance issues. Client came up with a nighttime routine to drink camomile tea 30 minutes before bedtime and prayer. Client declined referral to psychiatrist for medication evaluation. Plan is to revisit client symptoms and psychiatry referral if symptoms persist. RTC 5/26/12 12:30PM--------------------------------------------------------------------------------------------Jayden Staff, PhD
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Section 5: Treatment Documentation cont. 3. Group Therapy and Group Rehabilitation Therapy, CCR Title 9, Division 1 §1810.250. “Therapy” (Individual or Group) means a service activity which is a therapeutic intervention that focuses primarily on symptom reduction as a means to improve functional impairments. Therapy may be delivered to an individual or group of beneficiaries and may include family therapy at which the beneficiary is present. Therapy maybe provided by licensed and waived staff (under clinical supervision) within their scope of practice. Rehabilitation, CCR Title 9, Division 1 §1810.234. “Rehabilitation” (Individual or Group) means a service activity which includes assistance in restoring, improving, and/or maintaining a beneficiary’s or group of beneficiaries’ functional skills, daily living skills, social and leisure skills, grooming and personal hygiene skills, meal preparation skills, and support resources; and/or medication education. Frequently Used Codes for Groups CPT Codes for Groups
HCPCS Codes for Groups
90849 - Multiple Family Group
H2015GT - Group Rehabilitation
90853 - Group Psychotherapy
H0036G - Family Treatment Group
90857 - Interactive Group Psychotherapy
H2015CG - Collateral Group H2015GD - DBT Group Therapy
Distinction between Group Psychotherapy and Group Rehabilitation Services: Group Psychotherapy• Only licensed, waived or registered mental health professionals may conduct group psychotherapy within their scope of practice. • Group Psychotherapy does not include physiological interventions, such as medications. • Psychotherapy groups include the use of psychosocial methods to help the client, including but not limited to achieving a better psychosocial potential and adaptation, acquiring greater human realization of psychosocial potential, insight, modifying internal and external conditions affecting behavior, emotions, and thought with respect to both intrapersonal and interpersonal processes. Group Rehabilitation• May be conducted by unlicensed, unwaived or unregistered mental health workers, such as Mental Health Rehab Specialists, as well as by licensed, waived or registered clinicians and adjunct staff, such as LVNs, Psychiatric Technicians and Pharmacists and does not include psychosocial or psychotherapeutic interventions. • Group Rehabilitation includes service activities that assist the client(s) in improving, maintaining or restoring functional skills, daily living skills, social and leisure skills, grooming and personal hygiene skills, meal preparation skills, and support resources including medication education (Note: Pharmacists may use this code for Medication Education Groups) Both Group Psychotherapy and Group Rehabilitation must be structured so that clients focus on specific goals/objectives that meet medical necessity and each client recieves individualized feedback from the group leader(s).
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Section 5: Treatment Documentation cont. Coding and Billing for Group Therapy/Rehabilitation If group therapy/Rehabilitation is an effective intervention, the client’s Treatment Plan of Care must address what issues are being addressed for the specific group the client is participating in. Staffing: Within scope of practice If group is co-staffed, each staff member must have a documented unique, unduplicated role. Billable Activities Related to Groups: There are three billable group therapy related activities: face-to-face group therapy between therapist and clients; travel; and documentation. NOTE: Neither Travel time nor Documentation time can be billed to Medicare! ▶▶Face-to-Face time (FTF): this is direct service time with the clients. ▶▶Travel: travel time is that time you travel from your office to the site where group is held. ▶▶Documentation: writing an individualized progress note for each client participating in the group session.
NOTE: Conducting research for group/ individual activities/interventions, investigating clinical topics on the internet or reading an article is NOT a billable service! Documentation for Groups: 1. You will document in Avatar Progress Notes. There are templates that help prompt the documentation that is required. 2. You will select the correct service document for the type of service you are providing. 3. Any service you provide, document, code and bill must be a service that your program is authorized to provide. 4. Any service you provide must be within your professional scope of practice. 5. The number of client participants are to be included in the “total number” of participants, regardless of funding stream. 6. All Group Notes require that each note is “individualized” to each client participant and their individual benefit receptivity and behavior during the group. The progress note examples are to show a comprehensive narrative note that meets criteria for the service code. Location/Duration and other drop down selections that Avatar uses are NOT present in these example notes.
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Section 5: Treatment Documentation cont. Descriptions and Types of Groups: 90849 – Multiple Family Group Psychotherapy This therapy is insight-oriented, behavior modifying and /or supportive therapy when there are multiple family groups and similar dynamics for clients are being treated. This code is frequently used in hospitals and drug treatment centers where psychotherapy with several different families takes place regarding their issues surrounding hospitalization of the client or the client’s abuse of substances. Clients may or may not be present, but the focus must include the clients’ problems, not just the family members’ problems. The therapist completes an Avatar Group Progress Note for each client represented in the group. 90853 – Group Psychotherapy Group psychotherapy is a form of treatment in which a selected group of approximately 8 -10 clients are guided by a licensed psychotherapist for the purpose of helping to effect changes in maladaptive patterns which interfere with social functioning and are associated with a diagnosable psychiatric illness. The therapist completes a billing slip for each client in the group. Examples: Anger Management Group, Bereavement Group, Group Therapy for children experiencing domestic violence, Group Therapy for children with anxiety disorders. 90857- Group Therapy/Interactive Interactive group psychotherapy is used when clients in a group setting do not have the ability to interact by ordinary verbal communication; therefore, non-verbal communication skills are employed, or an interpreter may be necessary. Interactive procedures are distinct forms of diagnostic procedures and psychotherapeutic procedures which predominately use non-verbal communication (sign language interpreters, visuals aids, computer monitors, etc.) and physical aids (dolls, toys, inanimate objects) to overcome barriers to therapeutic interaction between the clinician and the patient who has lost or who has not yet developed either the expressive language communication skills to explain his/her symptoms and response to treatment, or the receptive communication skills to understand the physician if he/she were to use verbal communication. Examples are Group using interactive activities to reduce or eliminate the emotional, cognitive, neurovegetative, or behavioral symptoms sufficient to interfere with normal functioning, being experienced by the client; Group puppets to treat children abused at a young age, or who are filled with traumatic images; Group using a language interpreter to communicate with group members. H2015GT - Group Therapy/Rehabilitation This code is used for services that are provided by a unlicensed, unwaived, not-registered staff , or RN, LVN, LPT, Pharmacists, MHRS, and OTR. Examples are Rehabilitative group for schizophrenic adults, Anger Management Group led by a HCPCS code user (non-CPT user). Rehabiltation Welcoming/Orientation (depending on content) Healthy Living, Stress Management (including Smoking Cessation - nonmedical perspective) Effective Communication Life-skill Groups (independent living)
Group Examples Therapy Psycho-educational Psycho-therapeutic (including Trauma Focus Therapy) Cognitive Behavioral Dialectical Behavior Therapy (DBT)
Medication Psycho-pharmacological (medication, side-effects, etc) Smoking impact on Medication and Health Medication related weight gain Medication management
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Section 5: Treatment Documentation cont. Sample Note for 90853- Medi-Cal/Medicare Client: Group (co-staff) CHILD or ADULT 90853 (CPT users) or H2015GT (HCPCS user) Group focus: Anger Management Skills. The focus of today’s group was identifying events which have triggered outbursts of anger that were difficult to control. Group members listed 3 triggers of their own and then shared these with the group. Individual Treatment Goal: Client will use words to express feelings of frustration when overwhelmed instead of getting angry. Co-facilitated group with Lucinda Staff, MHRS. Lucinda introduced concepts of family of origin and anger (see Lucinda Staff Note) whereas I focused on how to effectively identify anger triggers. Client Participation: Client attended group complaining that he did not want to participate. He was able to listen attentively to other participants. We encouraged him to share his feelings when he was ready, and acknowledged how overwhelming it can be to feel angry. After quietly listening for most of the session, client identified the triggering events for his anger. Will continue attending group sessions. --------------------------------------------------------------------------------------Dante Staff, PhD Group Examples: ➢➢ Care Group–Rehabilitation ➢➢ Healthy Living type groups – Rehabilitation -if led by non-medical clinician. Coded Medication Support - if led by a medically licensed professional within their scope of practice and related to medication-related weight gain, impact of smoking on stress/anxiety, etc. ➢➢ Medication Groups - led by medically licensed professional within their scope of practice. ➢➢ Therapy Groups - DBT, Cognitive Behavioral Groups, Trauma Focused Therapy, Aggression Replacement Therapy, Seeking Safety Group, etc. ➢➢ Welcoming/Orientation Groups - Rehab depending on content. ➢➢ Triple P and Incredible Years
Sample Note for 90853- for Medicare/Medi-Cal Client: (co-staff) ADULT 90853 Group focus: Seeking Safety - Harshness vs. Compassion self-talk. The focus of today’s group was asking clients to understand and rehearse compassionate approach to themselves. The goal was to replace negative/harsh self-talk with positive/compassionate approach to promote change. Individual Treatment Goal: Client will identify a recent situation in which she used harsh self-talk that resulted in her binge drinking. She will practice out loud how talking compassionately might have prevented this behavior. Co-facilitated group with Keith Staff, MFT. Keith introduced concepts of harsh vs. compassion self-talk, and provided psychoeducation on how that relates to traumatic symptoms and substance abuse. We both rehearsed and role-played compassion self-talk in front of the group. Client Participation: Client attended group complaining that she did not want to participate. She was able to listen attentively to other participants. We encouraged her to share her thoughts and feelings when she felt ready to engage. After quietly listening for most of the session, she joined in and was able to connect with the group. She shared with the group “I feel like a loser right now because I drank with my boyfriend last night.” With the groups support, she was able to practice compassionate self-talk and reported feeling better at the end of the group. Plan: Between now and the next session, client will continue to practice compassionate self-talk. Next group meeting date/ time.------------------------------------------------------------------------------------------------------Ravi Staff, PhD
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Section 5: Treatment Documentation cont. Group Notes and Co-Practitioner Time Calculations: 1. ALL practitioner durations for GROUP services will be appropriately used during calculation of the final calculations for the GROUP billing. 2. For State of California Short Doyle MediCal, co-practitioner is used for calculations in billing. 3. At the time of the CLAIM COMPILE, the total time for practitioner, and co-practitioner time will be added together. 4. For GROUPS, the calculation is: total duration practitioner + duration co-practitioner divided by the total number in the group. The final calculations are NOT visible on the Client Ledger but will calculate correctly at the time of the claim. See Avatar Guidelines. Click Here
Group Name/ID#
Option “Group Registration” requires a selected “Group,” Please select one.
Alternate Lookup
Alternate Lookup Type
Process Alternate Lookup Search
Select Group
ok
Cancel
New
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Section 5: Treatment Documentation cont. 4. Collateral Services Collateral, CCR Title 9, Division 1 §1810.206. “Collateral means a service activity to a significant support person in a beneficiary’s life with the intent of improving or maintaining the mental health status of the beneficiary. The beneficiary may or may not be present for this service activity.” Significant Support Person, CCR Title 9, Division 1 §1810.246.1. “Significant Support Person” means persons, in the opinion of the beneficiary 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 a beneficiary who is a minor, the legal representative of a beneficiary who is not a minor, a person living in the same household as the beneficiary, the beneficiary’s spouse, and relatives of the beneficiary.”* * For SFDPH, Community Programs, this may include domestic partners. CPT Codes
HCPCS/Other Codes
for Collateral Services
for Collateral Services
90846- Family Therapy without Client Present
H2015CI - Collateral- Individual Rehab
90847- Family Therapy with Client Present
H2015CG - Collateral Group Rehab
90849- Multi- Family Therapy
H0046- Collateral Not Family or Guardian H2019C- TBS Collateral NMCOL-Collateral Non-Billable IFSO
90846 – Family Therapy w/o Client Present (Medicare Only) In family psychotherapy, the family is brought into the treatment process. Dynamics within the family structure as they relate to the client are the main theme of this type of psychotherapeutic session. The emphasis is on the client’s care but therapy is aimed at the environment in which the client lives and the interactions of the family. Examples include meetings with parents to discuss child’s progress in treatment; meeting with adult child of client to discuss client’s current functioning and how s/he might be involved: meeting with legal guardian to review client’s progress. Note: "Family" is defined by Medicare as immediate family members (husband, wife, siblings, children, grandchildren, grandparents, mother, father), and includes live-in companions or signficant others, and primary caregiver who provides care on a voluntary, uncompensated, regular, sustained basis, guardian, or health care proxy. This is the definition of “family” that must be used when billing for Medicare clients.
90847 – Family Therapy with Client Present (Note: Client must be present to claim Medi-Cal) This type of therapy does not change in scope from that of CPT Code 90846 except that the client is present (See aforementioned Medicare definition for “family”). Examples include Family Therapy with client and mother, father and sister, Familiy Therapy with client and spouse, Family Therapy with client and legal guardian.
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Section 5: Treatment Documentation cont. When providing a service activity that involves contact with significant support person(s) other than those who meet the definition of “family” in the client’s life, use Collateral H2015CI (for individuals) or H2015CG (for groups) H2015CI – Collateral (Individual Rehab) Collateral services are activities to significant support persons in a client’s life with the intent of improving or maintaining the mental health status of the client. This significant person will help the client meet his/her Plan of Care Goals. The client may or may not be present for this support service activity. A collateral progress note documents how the provider educates the significant support person in the implementation of the plan. Collateral is billed when the support person can work “with” the client around the client plan as a result of the collateral contact. This code is used when the service is provided by any staff, whether a CPT User or a HCPCS User. ➢➢ Collateral progress notes must include what was instructed or shared with the support person and how the support person will work with the client regarding the plan, or what the support person did or will do to work with client on the plan. ➢➢
This code is also used for any telephone contact made to family members or significant support persons in the client’s life in which you are discussing the client’s treatment. Examples include: telephone call to teacher at client’s school to discuss his classroom behavior; call to day treatment program to determine client’s progress; call to Housing Manager to discuss client’s behavior; Rehabilitation Counselor meets with client’s father to discuss his participation in client’s treatment
H2015CG - Collateral Group Rehab Collateral Group Rehab services are activities to a group of significant support persons in a client’s life with the intent of improving or maintaining the mental health status of the client. This significant person will help the client meet his/her Plan of Care Goals. The client may or may not be present for this support service activity. A collateral progress note documents how the provider educates the significant support person in the implementation of the plan. Collateral is billed when the support person can work “with” the client around the client plan as a result of the collateral contact. This code is used when the service is provided by any staff, whether a CPT User or a HCPCS User. USE HCPCS CODES WHEN COLLATERAL SERVICES ARE WITH PEOPLE WHO ARE NOT DEFINED AS “FAMILY” PER MEDICARE, AND FOR ALL TELEPHONE CONTACTS. FACILITY STAFF MEMBERS ARE NOT CONSIDERED SIGNIFICANT OTHERS IN MEDICARE. Sample Note for 90846- Medicare Only Client: Family Therapy without client present 90846 8/30/11 Met w/client's mom to discuss interventions for his aggressive outbursts towards his siblings when client returns from visiting w/ father. These behaviors have increased in frequency and have become more significant in the past 2 months, and per mother, father agitates the situation. Discussed ways in which mother can help support client before and after visits. Discussed the option of having another adult be present at visits for client to feel safe and someone else can intervene during conversations. Mother is looking for legal help to get supervised visitations and is asking father to take parenting classes. Anger intervention plan discussed and mom will practice these interventions with client. Referred mom to SF Legal Services for legal advice. RTC 9/15/11---------------- Barbara Staff, LCSW
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Section 5: Treatment Documentation cont.
Sample Note for 90846- Medicare Only Client: Family Therapy without client present 90846 8/30/11
Met with client’s spouse to discuss how she could support him in working on his treatment goals to prevent relapse in his anger management. She indicated some concern about his relapsing, and feels as though it is difficult to confront him when he is angry. I asked if she felt that she could bring this up in our next family session with client so that it can be discussed openly and we can work through these issues. She felt she could do this with therapist’s support. Role played several scenarios that can help client in his recovery goals. Next session on 9/15/11------------------------------------------------------------------------------------------------------Nigel Staff, LCSW Sample Note for H2015CI- Medi-Cal Client: Collateral with Teacher CHILD H2015CI 8/30/11
Traveled to client’s school and met w/ client’s teacher to discuss his behavior in school. She is using the techniques that we discussed 3 weeks earlier, and has seen significant progress in controlling and redirecting intrusive and clingy behaviors. She indicated that he responds well to an increased level of structure. Teacher requested that I observe him in the classroom setting in order to provide her with additional feedback. Plan is to continue with the current intervention plan. RTC on 09-14-11 4:40PM--------------------------------------------------------------------- ShuHua Staff, HW-IV Sample Note for H2015CI- Medi-Cal Client: Collateral with Hotel Manager on Phone ADULT H2015CI 8/30/11
Phone call w/client's hotel manager to discuss his aggressive outbursts towards others in the building. These have become more significant in the past 2 months and the manager indicates that he does not believe that client has been taking his medication regularly. Manager offered to help client in any way that he could, and asked if there were specific things he could do to help. We discussed client’s need for clear expectations and limits. We decided that Hotel Manager would attend our next meeting with the client on 9-15-11 at 4pm, so that we could talk with client together about the situation and make a plan. No additional help needed at this time.-----Barbara Staff, LCSW Sample Note for H2015CG- Medi-Cal Client: Collateral Group Rehabilitation ADULT or CHILD H2015CG 5/01/12
Group focus: Managing Anger with others Skill-building. The focus of today’s group was identifying “how to identify signs and symptoms of anger”? Individual Treatment Goal: Client will use words to express feelings of frustration when overwhelmed instead of getting angry with significant support persons in his life. Present at today’s collateral group included client’s supportive neighbor, his best friend and his girlfriend. Discussed with group what are signs and behaviors of anger. Client Participation: Client and group specifically identified how client’s face turns red and how he clinches his teeth prior to an angry outburst. Client accepted feedback and agreed with group observation. Role-modeled in group how to re-direct anger by counting to ten, deep breathing, letting others know his discomfort and personal need to take a “time-out”. Group positively reinforced client’s effort to take responsibility to control his angry outburst. Plan is for client to practice skills and significant support persons to positively reinforce client for effectively practicing ways to redirect his anger. Next meeting set for 6/01/12 at 12 noon.----------Joyce Staff, HW-III (Joe Staff, LCSW co-signer) Collateral (Individual) services are not billable to Medicare, so there is no sample note for Medicare clients. Only Family Psychotherapy provided by a CPT user can be billed to Medicare.
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Section 5: Treatment Documentation cont. 5. Case Management Services Targeted Case Management, CCR Title 9, Division 1 §1810.249. “Targeted Case Management means services that assist a beneficiary to access needed medical, educational, social, prevocational, vocational, rehabilitative, or other community services. These service activities may include, but are not limited to communication, coordination, and referral; monitoring service delivery to ensure beneficiary access to service and the service delivery system; monitoring of the beneficiary’s progress; and plan development.”
CPT Code Case Management 90882- Environmental Intervention 90885- Psychiatric Records Evaluation 90887- Interpret or Explain Psychiatric Information 90889- Psychiatric Report Preparation
HCPCS Codes Case Management T1017- Case Management Brokerage T1017-Case Management Report Preparation T1017DB- DBT Case Management T1017P- Case Management Inpatient Short-Doyle IPT1017- Case Management Fee For Service Inpt.
None of these services are billable to Medicare in California, so all examples provided are for Medi-Cal clients only. 90882 – Environmental Intervention An environmental intervention for medical and/or psychological management on the client’s behalf with agencies, employers or institutions, e.g. advising a teacher/employer to change something about the client’s environment to aid in managing the client’s condition. This code is used ONLY when services provided are not described in another CPT code. Environmental Intervention cannot be billed to Medicare. Sample Note for 90882- Medi-Cal Client: Environmental Intervention 90882 5/20/12 I discussed with the client’s supervisor work strategies that might help the client better manage her anxiety by changing her job assignment (e.g. less stressful activities). Plan is to follow-up with client’s supervisor to see if this strategy was successful. -----------------------------------------------------------------Tyrone Staff, PhD
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Section 5: Treatment Documentation cont. 90885-Psychiatric Record Evaluation for Report (record review) A qualified mental health provider is asked to evaluate hospital records or other client specific data and develop a report for other agencies or individuals. It may also be used for review of psychiatric reports. Examples include: Clinician reviews records to write a report requested by a third party; A clinician reviews educational, psychological, and medical records in order to write an AB3632 report requested by an IEP team; Clinician reviews records to write a report for the court. Sample Note for 90885- Medi-Cal Client: Record Review for Report 90885 8/30/11 Reviewed documents from previous placements and other team members in order to develop a report for client’s county case manager.-------------------------------------------------------------------------- Melba Staff, MFT
Note: This ode is not to be used to review your own previous notes or reports. 90887- Interpret or Explain Psychiatric Evaluation Interpretation or explanation of results of psychiatric, other medical examinations and procedures, or other accumulated data to family or other responsible persons, or advising them how to assist patient. Examples include: A clinician meets with a child’s parent to explain the results of a completed mental health assessment; After completing psychological testing, clinician meets with teacher to explain the results of the testing; Psychologist shares with Drug Court Judge results of MMPI administered to client, to help determine if client is appropriate for Drug Court. 90889- Psychiatric Report Preparation The preparation of a written report of a client’s psychiatric status, history, treatment, or progress (other than for legal or consultative purposes) for other physicians, agencies, or insurance carriers, the document produced should clearly establish medical necessity. This code should be used when a mental health professional prepares a report on a client’s psychiatric status. This is frequently referred to as a “progress report” and is required by many third-party payers before they will authorize additional mental health services. Examples include: Clinician completes report on client’s progress for probation/parole office/SSI/DHS. ▷▷ While there are no hard and fast “rules” as to what information should be included in a report of this nature, any document generated should clearly establish medical necessity for ongoing therapy. Transcription services are not billable. Sample Note for 90889 - Medi-Cal Client: Psychiatric Report Preparation for CPT User 90889 Completed court ordered report on client’s progress in program. Addressed successful behavioral changes and continued improvement. Plan is to continue to monitor and provide updates as required.--Carlos Staff, NP
T1017 - Report Preparation for HCPCS User Preparing a report for continuing services should reference documents completed and service requests. Sample Note for T1017 - Medi-Cal Client: Report Preparation for HCPCS User T1017 Prepared report on client’s progress for Family Mosaic Project regarding clients’ current functioning and made request for continuing services. Client’s current Diagnosis: Oppositional Defiant Disorder. Client currently at risk of losing placement due to property destruction and verbal threats towards authority figures. --------------------------------------------------------------------------------------------------------------Sally Staff, MHRS
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Section 5: Treatment Documentation cont. Lockouts for Case Management (a) (b)
Targeted Case Management Services are not reimbursable on days when the following services are reimbursed, except for day of admission or for placement services as provided in subsection, 1. Psychiatric Inpatient Hospital Services 2. Psychiatric Health Facility Services 3. Psychiatric Nursing Facility Services
Targeted Case Management Services provided in the above settings must be strictly related to decision-making and activities related to the client’s placement and may only be billed for 30 days prior to discharge. The maximum number of times you may use this service is 3 non-consecutive periods of 30 calendar days or less per continuous stay in the facility. For more information on coding of services in these facilities, please see Section called ‘Services To Clients in Inpatient, IMD, MHRC, Psychiatric or Skilled Nursing Facility’ Also see Section called ‘Billing for Services Provided to Incarcerated Clients1 1
Excerpt from CCR Title 9, Div. 1 §1840.374
Sample Note for IPT 1017 - Medi-Cal Client: Case Mgmt. in Fee For Service (FFS) Hospital IPT1017 Met with hospital social worker and client at McAuley Adolescent Institute inpatient unit to discuss placement and discharge plan. Client will need to be linked to an outpatient CYF provider for individual, collateral and medication support services. Will follow-up with County provider and set-up an appointment for client. -------------------------------------------------------------------------------------------------------------------------Miriam Staff, RN
Sample Note for T1017P - Medi-Cal Client: Case Mgmt. in Short-Doyle (San Francisco General Hospital) T1017P Met with Inpatient discharge planner and client at SFGH to discuss placement options and discharge plans. Client was evicted from his previous Board and Care and will be homeless upon his anticipated discharge this Friday. Client states he would like to have his own room and is agreeable to more intensive placement setting. Discharge planner and I will work on ACT home placement plans. -------------------Vincy Staff, ASW
NOTE: Cannot claim for any services, including Case Management, for clients in an IMD, Inpatient setting. Use T1017N for non-billable Case Management services provided while client is in these settings. Sample Note for T1017N - Non-Billable Inpatient Client: Case Mgmt. in Psychiatric Hospital/Institute for Mental Diesease (IMD) T1017N Called Inpatient discharge planner at St. Helena Hospital-Center for Behavioral Health to discuss placement options and discharge plans. Client was transferred to the Vallejo facility when no psychiatric beds available in Bay Area. Discussed with D/C planner housing options and appropriate placement setting. Discharge planner and I will work on Board and Care home placement plans. -----------------Luis Staff, LCSW
NOTE: After Discharge from Inpatient, claim T1017 for Case Management outpatient.
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Section 5: Treatment Documentation cont. 6. Medication Services Including Evaluation and Management Medication Support Services, CCR Title 9, Division 1 §1810.225 “Medication Support Services” means those services that include prescribing, administering, dispensing and monitoring of psychiatric medications or biologicals that are necessary to alleviate the symptoms of mental illness. Service activities may include but are not limited to evaluation of the need for medication; evaluation of clinical effectiveness and side effects; the 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 service and/or assessment of the beneficiary. NOTE: The client’s progress notes should include the evaluation of the client’s signs and symptoms, the response to medication, consideration of drug interactions, adverse drug effects when applicable, and any changes in dose and medication(s) prescribed, when applicable. Department of Health Care Services (DHCS) DHCS has elaborated on the definition of Medication Support Services to include one or more of the following: “prescribing, administering, dispensing and monitoring drug interactions and contraindications of psychiatric medications or biologicals that are necessary to alleviate the suffering and symptoms of mental illness. This service may also include assessing the appropriateness of reducing medication usage when clinically indicated. Medication Support Services are individually tailored to address the beneficiary’s need and are provided by a consistent provider who has an established relationship with the beneficiary. Services may include: providing detailed information about how medications work; different types of medications available and why they are used; anticipated outcomes of taking a medication; the importance of continuing to take a medication even if the symptoms improve or disappear (as determined clinically appropriate); how the use of the medication may improve the effectiveness of other services a beneficiary is receiving (e.g., group or individual therapy); possible side effects of medications and how to manage them; information about medication interactions or possible complications related to using medications with alcohol or other medications or substances; and the impact of choosing to not take medications. Medication Support Services supports beneficiaries in taking an active role in making choices about their mental health care and helps them make specific, deliberate, and informed decisions about their treatment options and mental health care. Medication support services may be provided face-to-face, by telephone or by telemedicine with the beneficiary or significant support person(s) and may be provided anywhere in the community. This service incudes one or more of the following service components: • • • • • •
Evaluation of the need for medication Evaluation of clinical effectiveness and side effects The obtaining of informed consent Medication education including instructions in the use, risks and benefits of and alternatives for medication Collateral Plan Development
Providers: Medication support services may be provided within their scope of practice by a Physician, a Registered Nurse, a Certified Nurse Specialist, a Licensed Vocational Nurse, a Psychiatric Technician, a Physician Assistant, a Nurse Practitioner, and a Pharmacist. Limitations: The maximum number of hours claimable for medication support services in a 24-hour period is 4 hours. This service is not duplicative of the drug counseling requirements described in 42 CFR 456.705.”
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Section 5: Treatment Documentation cont. Medication Scope of Practice Consistent with scope of practice, Medication Support Services may be provided by the following staff: • Licensed Physician (MD/DO) • Mental Health Nurse Practitioner (NP) • Registered Nurse (RN) • Clinical Nurse Specialist (CNS) • Licensed Vocational Nurse (LVN) • Licensed Psychiatric Technician (LPT) • Licensed Pharmacist (PharmD, RPh)
Frequently used CPT codes for Medication Support Services Physician and Nurse Practitioner claiming ONLY (face-to-face) 90862 - Pharmacological Management w/ Minimal Psychotherapy M0064 - Brief Medication Visit (Office/Clinic site only) 90805 - Ind. Therapy w/ E&M (20-44 Mins.) 90807 - Ind. Therapy w/ E&M (45-74 Mins.) 90811 - Interactive Ind. Therapy w/ E&M (20-44 Mins.) 90813 - Interactive Ind. Therapy w/ E&M (45-74 Mins.) 90801 - Psychiatric Diagnostic Interview Examination NOTE: Codes 90862 and M0064 describe a physician/nurse practitioner service. The practioner/prescriber who provides either of these services must be licensed by the State to prescribe psychoactive medication.
Frequently used HCPCS codes for Medication Support Services All other Med Support Staff (including MD/DO/NP with no face-to-face) H2010DB - DBT Med Support/Monitoring H2010GP - Medication Group H2010MT - Medication Support/Monitoring There are many additional codes that reflect evaluation and management services that may be provided for MDs/ DOs/NPs. We have listed the most widely used within the SFDPH, Community Programs system. IMPORTANT: Effective January 1, 2013 some CPT codes for Medication Support Services (90862, 90801) will become obsolete, and will be replaced with E & M codes. Please refer to American Medical Association guidelines or contact the Chief Medical Officer with any questions. See Appendix J for CPT coding changes, 2013.
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Section 5: Treatment Documentation cont. 90862 – Pharmacological Management with Minimal Psychotherapy Code 90862 is indicated for the patient who is managed primarily with psychotropic drugs. There are no specific time limitations on this code. This code can be used for services provided in the office or in the client’s home. Pharmacologic management is distinguished from brief pharmocologic management because the latter is a brief visit for the sole purpose of monitoring or changing drug prescriptions used in the treatment of mental psychoneurotic and personality disorders. The psychotherapy provided in conjunction with the reporting of CPT code 90862 is very minimal (generally less than 10 minutes) and is basically supportive. When the client is an established client (including one that is new to the Prescriber (MD/DO/NP) but has been seen by others in the system and has a completed assessment e.g., 90801), then the Prescriber could bill for 90862 or M0064 if the evaluation is focused on Medication Support. M0064 – Brief Medication Visit Medicare Code M0064 requires less work than 90862. The patient is stable, but still requires pharmacologic regimen oversight. Services include an evaluation of the safety and effectiveness of the medication and/or a simple dosage adjustment to long-term medication. The prescription may remain unchanged. Limited to not more than 20 minutes of medication service on this code; it is expected to be a brief face-to-face contact. Example includes an appointment with client who is receiving only medication management services, and is stable. This service may be provided only in an office/clinic setting. NOTE FOR MEDICARE ONLY CLIENTS: 1. 90862 and M0064 are not payable to Medicare with an Evaluation & Management (E&M) code (CPT code range 99201-99499) or with a psychotherapy service containing an E&M component (90805, 90807, 90811, 90813) for the same patient on the same date of service. 2. According to Medicare, only one psychotherapy service per day per client within a group practice may be provided. If a therapy service is provided by one professional (e.g., 90804, 90806) then a second professional cannot bill for a 90862 on the same day. Instead, code M0064 would be used to describe the pharmacologic management provided.
Medication Support Activities Not Billable to Medicare, but can be claimed to Medi-Cal HCPCS Codes ➢➢ Time spent filing out disability and other reports, writing letters with clinical content, managing documentation ➢➢ Conferences with team members during which the MD/DO or NP imparts medical information ➢➢ Services provided over the phone ➢➢ Time reviewing chart without client present for prescribing or assessment NOTE: When providing a service that is not primarily medication support, medication support staff must use the relevant service code billing associated with the service provided,( e.g. case management, therapy, collateral, etc.)
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Section 5: Treatment Documentation cont. Other Medication Support Service Codes 90801- Psychiatric Diagnostic Interview Examination This code is used to bill for the face-to-face assessment of a client by any MD/DO, NP, LCSW, MFT, PhD/PsyD, CNS, registered or waived staff. If it requires more than one session to complete the assessment, document the need for additional sessions in a progress note. A psychiatrist and a clinician may both complete an assessment and use this code for the same client when completing assessment documents. (If an MD/DO or NP is doing only a limited assessment designed to prescribe medications, s/he may use 90862 – see Medication Section for details). Examples include: Initial Assessment by Clinician; Initial Assessment by Psychiatrist; Annual Assessment Update; Re-Assessment for a client who has returned to treatment. 90805 – Individual Therapy with Evaluation and Management (20-44 Minutes) This service is similar to 90804 (Individual Psychotherapy) but with medical evaluation and management services. It is used for managing medication when the psychiatrist is available to engage in more than a review of medication with a client, has a definitive therapeutic communication (verbal and non-verbal) with the client, and is using the therapeutic relationship to help facilitate a reversal or change of maladaptive behaviors. Examples include: 20-44 minute scheduled appointment with a client for managing medication when the psychiatrist is providing any type of psychotherapy. 90807 – Individual Therapy with Evaluation and Management (45-74 Minutes) Same as 90805 above, but lasts 45-74 minutes 45-74 minute scheduled appointment with a client for managing medication when the psychiatrist or nurse practitioner is providing any type of psychotherapy; 45-74 minute scheduled appointment with a client with a psychiatrist that has a specialized skill that is not otherwise available, and the intervention has been determined to be medically necessary (specific phobias, borderline personality, etc). 90811 – Interactive Individual Therapy with Evaluation and Management (20-44 Minutes) This service is the same as 90805 above, but requires that the psychotherapy is provided using physical aids (e.g., hand puppets or interpreter) and non-verbal communication to overcome barriers to therapeutic interaction between the physician or nurse practitioner and client who has lost or not yet developed expressive language communication skills or receptive communication skills. This service is typically provided to young children who require special techniques such as “play therapy,” or when using an interpreter or sign language. 90813 – Interactive Individual Therapy with Evaluation and Management (45-74 Minutes) This service is the same as 90805 above, including the use of Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms on non-verbal communication, in an office or outpatient facility, approximately 45 to 74 minutes face-to-face with the patient. H2010MT – Medication Support Medication Support/Monitoring/Comprehensive Medication Services translated to H2010 are defined in Title IX and are described as prescribing, administering, dispensing and monitoring of psychiatric medications or biologicals which are necessary to alleviate the symptoms of mental illness. These services may include evaluation of clinical effectiveness and side effects, the obtaining of informed consent, medication education and plan development related to the delivery of the service and/or assessment of the client. Includes “plan development” related to the delivery of this service and/or to the status of the individual’s community functioning. This code is used when services provided cannot be described in a CPT code and when medication support services are provided and cannot be billed under the previously described CPT codes (90862, M0064, 90805, 90807, 90811, 90813).
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Section 5: Treatment Documentation cont. H2010MT HCPCS Medication Support Service Descriptions
STAFF: All Medication Support Staff MD/DO/NP: when services provided cannot be billed in a CPT code RN/CNS/LVN/LPT/PharmD: when consistent with scope of practice Medication Support Service Service Description Monitor and assess psychotropic medication Evaluation of clinical effects of medication adherence, tolerability and response. Adjust medication regimen including drug, dose, Medication regimen adjustment frquency, and time of day to optimize response and adherence to medications. Inform client of medication risk and benefits. Obtaining informed consent for medication Discuss alternatives to psychotropic medications. Obtain signed informed consent. Provide client or significant support person education regarding the proper use, benefits, Medication education risks, and side effect management of medications. Develop medication related treatment plan goals. Medication plan development Assess client’s progress towards medication related treatment plan goals. Review medication orders, confirm client Medication administration or dispensing identity, assess response and side efects, administer or dispense medications. Client specific consultations with providers or Medication related consultation with providers treatment team about client’s medications. Phone calls to client and significant support Contact client or significant support person by persons about medications phone to discuss medications. Communicate with pharmacy, prepare Phone calls to pharmacy and transmitting prescription orders for transmission, authorize medications orders prescription refills, resolve issues related to client’s prescriptions. Sample H2010MT – Medication Support Client contacted this pharmacist by phone requesting Medication consult. Provided medication education regarding client’s current regimen, including dietary restrictions and potential side-effects of medication. Plan is for client to take medication, as prescribed and follow-up with Dr. Lee in two weeks or earlier if needed.-----------------------------------------------------------------------Kwan Staff, PharmD
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Section 5: Treatment Documentation cont. Sample 90807 – Individual Therapy with Evaluation and Management (55 Minutes session) A 32 year old female treated for Major Depressive Disorder. Following discussion of on-going depression, she is taught cognitive restructuring. Client is also given the homework assignment to monitor one situation in the next week in which she found herself becoming more upset than she’d like to be and to document that situation according to the skill she was taught. Her responsiveness to the recently prescribed antidepressant medication Prozac is assessed and any compliance and side effect issues and/or concerns are addressed.----------------------------------------------Jose Staff, MD Note: 90805, 90807 and 90809 are time dependent. If the service lasted between 20-44 minutes, bill 90805 instead. If the service lasted more than 75 minutes, bill 90809 instead.
Note: For initial assessment by a Physician or a Nurse Practitioner for Adult/Older Adult System Of Care clients in acute Residential placement, use H2010 in lieu of 90801.
Sample 90813 – Interactive Individual Therapy with Evaluation and Management (61 Minutes) A 6-year-old, Hispanic male treated for ADHD and anger management issues. Today, we used puppets to interact. During course of play, Manny states he is upset with parents divorce. Manny taught how to redirect anger towards parents separation by using words to express feelings; encouraged and reinforced Manny to use drawings to illustrate his negative thoughts and feelings, and to come up with an alternate solution. Currently evaluating possible medication trial to address ADHD symptoms. Plan is to provide psychoeducation to mom and discuss risk/benefit of medication options. --------------------------------------------------------------------------------------------------------------Leticia Staff, MD Note: 90811, 90813 & 90815 are time dependent. If the service lasted between 20-44 minutes, bill 90811 instead. If the service lasted more than 75 minutes, bill 90815 instead.
NOTE FOR Physicians/Nurse Practitioners: When a Physician or Nurse Practitioner performs a full assessment on a client that is new to SFDPH, Community Programs (has never been seen in the system and does not have an assessment), s/he bills 90801, Psychiatric Diagnostic Interview Examination. Sample 90801- Psychiatric Diagnostic Interview Examination In our initial session, conducted a comprehensive assessment. I summarized and assessed the presenting problem, evaluating and reviewing the behavioral triggers, and impact of consequences of the behavior. Reviewed with significant support persons their perception of problem behavior, completed intake assessment. Plan is to work with client and support persons on formal Plan of Care (see assessment). Will refer client to Dr. Smith for medication evaluation. RTC on 12/15/11 at 10am--------------------------------------------------------------------------------------------------------Joe Staff, LCSW
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Section 5: Treatment Documentation cont. Other Medication Support Service Codes cont. “One-Shot” Medication Evaluation: One-Shot Medication Evaluations occur when a Medication Support Service is open and closed on same day and is typically provided for a brief Medication Support Service requiring prescriptive Medication Support (such as a refill prescription or change of medication). If the client has a previously completed comprehensive assessment, the prescriber can conduct a brief review, a brief interview with the client and/or support person and provide a brief medication support service. If no previous contact is recorded in the Electronic Health Records, the MD/DO/NP may conduct a Psychiatric Diagnosis Interview Exam (claimed under 90801) followed by the prescriber’s brief medication evaluation. The MD/DO can claim for: ➢➢ M0064 for brief Med mgmt. only; monitoring or changing Meds (less than 20 mins) ➢➢ 90862 for Medication Mgmt.; use & review of Meds with minimal psychotherapy (21+ mins)
Medication Only Clients: Medication Only clients must still meet Medical Necessity criteria for continued service. Prescriber staff must complete an annual assessment/client Plan of Care that supports Medical Necessity and the need for continued service. The Meds Only TPOC must include evidence of client participation as evidenced by the client or caregiver’s signature on the Meds Only TPOC.
For ALL phone calls, use a HCPCS code!! Lockouts/Limits for Medication Services The maximum amount claimable to Medi-Cal for Medication Support Services in a 24-hour period is 4 hours per beneficiary. For Short-Doyle Medi-Cal (SDMC) Hospitals: Medication services are considered by Short-Doyle (SDMC) as Outpatient Mental Health Services, therefore, they cannot be reimbursed when a client is in a SDMC psychiatric hospital (e.g., SF General Hospital). However, you can provide targeted case management services, and these are coded as T1017P. For Fee-for-Service Hospitals: Medication services are claimable when client is in a fee-for-service hospital (e.g, McAuley Adolescent Unit and St. Francis). Use IPT1017 to bill for targeted case management services while a client is placed in a fee-for-service hospital. Medication Services may be billed when a client is in a residential treatment facility or day treatment program (no lock-out). Note: prior authorization must be in place for Medication Services.
Note: A current and valid medication consent is required for every psychotropic medication prescribed. Medication consents must be updated annually for minors. ➢➢ Medi-Cal Contact Exception: Medication Support Services do not require face-to-face or phone contact with the client or client’s caregiver (Title 9 CCR 1840.316(b)(4)) for the purpose of chart review and/or medication plan update for the determination of medical necessity for Medication Support Services.
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Section 5: Treatment Documentation cont. 7. Day Treatment Services Day Rehabilitation, California Code of Regulation, Title 9, Section 1810.212 “Day Rehabilitation” means a structured program of rehabilitation and therapy to improve, maintain or restore personal independence and functioning, consistent with requirements for learning and development, which provides services to a distinct group of individuals. Services are available at least three 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. Day Treatment Intensive, California Code of Regulation, Title 9, Section 1810.213 “Day Treatment Intensive” means a structured, multi-disciplinary program of therapy which may be an alternative to hospitalization, avoid placement in a more restrictive setting, with services available at least three hours and less than twenty-four hours each day the program is open. Service activities may include, but are not limited to, assessment, plan development, therapy, rehabilitation and collateral.
For additional information regarding Day Treatment and Adult Residential Treatment Services, please Click Here
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Section 5: Treatment Documentation cont. 8. Crisis Intervention Crisis Intervention, CCR Title 9, Division 1 §1810.209. Crisis intervention means service, lasting less than 24 hours, to or on behalf of a beneficiary for a condition which requires more timely response than a regular scheduled visit. Service activities may include but are not limited to assessment, collateral and therapy. Frequently Used Codes HCPCS / (AB3632) H2011 – Crisis Intervention Crisis intervention is an immediate, unplanned emergency response service enabling the individual to cope with a crisis, while maintaining his/her status as a functioning community member to the greatest extent possible. A crisis is an unplanned event that results in the individual’s need for immediate service intervention to cope with the situation. Crisis Intervention services are limited to stabilization of the presenting emergency. EXAMPLES: ▶▶ Assessment and evaluation of client while in crisis ▶▶ Collateral and consultation regarding the crisis situation ▶▶ Therapy focused on resolution of the crisis such as when client contacts you and indicates s/he is feeling suicidal ▶▶ Intervening in a family crisis that has escalated to the point that the police have been contacted ▶▶ School contacts you and you respond to report that a child is out of control and may have to be hospitalized you provide therapy and assessment crisis services to help him regain self-control
Documentation
Crisis Intervention progress notes shall address, at a minimum, the following: 1. A brief succinct narrative of the situation. Activity of individual or situation which jeopardizes individual’s ability to maintain community functioning. Document, if client is left untreated, he/she presents an imminent threat to themselves or others. 2. A description of relevant clinical details including precursors and events leading to the unplanned service; Urgency and immediacy of the situation should be clearly documented. 3. Current assessment of risk including what interventions were provided to decrease risk and ensure the client’s safety and/or the safety of others. 4. A description of what was attempted and/or accomplished by service staff at the time the service was being provided and what measures were taken to decrease, eliminate or alleviate danger, reduce trauma and/ or ameliorate the crisis. 5. A description of the client’s response(s) to the interventions and safety plan and (when appropriate), significant support person(s)’ involvement in client’s aftercare safety plan. 6. Well documented collateral and community contacts that will participate in follow-up, plan for subsequent follow-up, and/or aftercare issues, if applicable.
Lockouts for Crisis Intervention
CCR Title 9, Division 1 §1840.366. (a) Crisis intervention service is not reimbursable on days when Crisis Residential Treatment Services, Psychiatric Health Facility Services, Psychiatric Nursing Facility Services, or Psychiatric Impatient Hospital Services are reimbursed, except for the day of admission to those services. (b) The maximum amount claimable for Crisis Intervention in a 24-hour period is 8 hours.
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Section 5: Treatment Documentation cont. Crisis Intervention Addenda Documentation Guidance: Who New Client Adult? New Client CYF? Psychiatric Emergency Services (PES) Returning Client? New or Returning Client?
What If completing Comprehensive assessment Not Medicare or Medi-Medi Crisis Stablization Regardless if CPT or HCPCS User Crisis Phone Call
Type Medicare, Medi-Medi Only Medi-Cal
Code Billed
Adults/Older Adults
S9484
All
H2011
All
H2011
90801 H2011
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Section 5: Treatment Documentation cont. 9. Other Supplemental Mental Health Services Therapeutic Behavioral Services (TBS) - TBS is an intensive one-to-one, short-term outpatient treatment intervention for children and youth with serious emotional problems or mental illness who are experiencing a stressful transition or life crisis and need additional short-term specific support services. TBS must be needed to prevent placement in a group home at Rate Classification Level (RCL) 12 through 14 or a locked facility for the treatment of mental health needs or to enable a transition from any of those levels to a lower level of residential care. H2019 – Therapeutic Behavioral Services TBS is provided through agencies that have a specific contract with SFDPH, Community Programs. It is an individualized, short-term intervention and different progress notes are used for TBS providers in order to meet the documentation requirements. The service is coded using a HCPCS code because it is specific to California. For documentation standards refer to the State DMH TBS Documentation manual and Service Function Code 58 can be found on-line Click Here For further questions or clarifi ations about this service, contact the SFDPH, Community Programs TBS Coordinator.
NOTE: Only programs specifically contracted by the City/ County of San Francisco can use H2019 TBS code
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Section 5: Treatment Documentation cont. 10. Discharge/Closing Summary Discharge summaries document the termination and/or transition of services and provide closure for a service episode and referrals as appropriate. A discharge summary can be claimed if the Discharge Summary meets the documentation requirements for services claims. ➢➢ Inclusion of an aftercare plan provided to the client and significant support person that include recommendations regarding follow-up treatment plan ➢➢ Community referrals and support systems provided. ➢➢ Medications prescribed including side effects or sensitivities and dosage schedules ➢➢ Essential information relative to the client’s mental health diagnosis, intervention course, rehabilitation potential. ➢➢ Expected course of recovery. ➢➢ Performance Outcome measures as required (e.g., CYF CANS closing and Adult/OA ANSA closing). ➢➢ Other relevant information as it applies. Claimable under H2015AS if providing discharge assessment, referral and linking the client to external resources at the time of discharge. Not Claimable: Discharge summary cannot be claimed for administrative tasks such as “closing out the chart, copying and/or filing.”
11. Clients in Hospital, Insititute for Mental Diseases (IMD), Mental Health Rehabilitation Center (MHRS), or Psychiatric Health Facility (PHF) or Skilled Nursing Facility (SNF) Frequently Used Codes HCPCS (AB3632)
T1017P
Case Management for the purpose of placement, provided to a client in San Francisco General Hospital or other Short-Doyle Medi-Cal Inpatient Hospital w/in 30 days of discharge (dis charge date must be entered)
IPT 1017 Case Management for the purpose of placement, provided to a client in a Fee For Service Inpatient Hospital w/in 30 days of discharge T1017P
Case Management for the purpose of placement, provided to a client in a Skilled Nursing Facility w/in 30 days of discharge
T1017N Case Management for the purpose of placement provided to a client in an IMD or MHRC (non- billable) T1017P
Case Management for the purpose of placement provided to a client in an ADU or Residential Treatment Facility (can bill for Med Support and Case Management only)
These codes are used for services provided to clients when they are placed in inpatient or skilled nursing facility settings.
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Section 5: Treatment Documentation cont. 12. Clients Who are Incarcerated In general, clients who are in a public institution (jail, prison, Youth Guidance Center) because of criminal activity are not eligible for Medi-Cal services. However, there are certain circumstances that may arise for a client, that will allow them eligibility, and therefore, allow the provider to bill for services. Both the facility and the status of the person must be considered when making a Medi-Cal determination of eligibility for either a juvenile or an adult who is incarcerated or placed in any type of public institution.
Billable Situations
(a) An individual in prison or jail who transfers temporarily (one to two months) to a halfway house or residential treatment facility prior to a formal release order. (b) Individuals released from prison or jail under a court probation order due to a medical emergency. (c) An Individual who served his/her sentence, can be released, but could not find placement in the community and is temporily housed on state property pending alternative placement. (d) A minor in a juvenile detention center prior to disposition due to care, protection or in the best interest of the child/youth (e.g., Child Protective Services) if there is a specific plan for that person that makes the stay at the detention center temporary (one to two months). This could include those juveniles awaiting placement but still physically present in juvenile hall. (e) A minor placed on probation by a juvenile court on juvenile intensive probation to a secure treatment facility contracted with juvenile detention center if the secure treatment facility is not part of the criminal justice system. (f) When a juvenile is a “Ward of the Court” and is adjudicated awaiting foster care placement and not awaiting sentencing for a criminal violation of law, the juvenile is eligible for Medi-Cal. NOTE: A copy of the “Adjudication order” for the purpose of placement (from the judge) MUST be in the chart in order to claim services!
If incarcerated client does NOT meet the above criteria You cannot bill for any Medi-cal of Medicare services. You may use the following code: T1017N (Non-billable)
Case Management/Brokerage
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Section 6: Appendix A Staffing Qualifications and Privileges
65
Section 6: Appendix B Hjfh;aks
City and County of San Francisco Department of Public Health
DPH COMPLIANCE OFFICE 1380 Howard St., 2nd Floor San Francisco, CA 94103
Certification and Verification for Staff ID Legibly PRINT OR TYPE responses. Your request will not be processed without an NPI number, supporting documentation, and both staff and supervisor signatures. Please submit your request two (2) weeks in advance. NO BILLING IS ALLOWED until verification and credentialing is finalized. NO RETROACIVE BILLING WILL BE ALLOWED.
For NEW REQUEST fax to: IT Accounts Coordinator: at 415-252-3008 For UPDATE fax directly to: DPH COMPLIANCE OFFICE at 415- 252-3032 PLEASE CHECK APPROPRIATE BOX BELOW:
*New
*Update Personal Info *Update Program Info*Update License/Certification
If updating information, please include your Staff ID #: _____________
Personal Information Last: __________________________ First: _______________________ MI: ___ Suffix: ____ (Sr., Jr.) SSN:____-____-_____
DOB: ___/___/____
Gender: ____
Program Information MH SA (for SA counselors who are certified or registered, you must provide a copy of certification/registration)
Program Name: __________________________________
RU/Program Code #_____________________
Street Address: ___________________________ City: _____________________
State: ______
Zip Code: ___________ Agency Phone: _____________ Agency Fax: ____________ License/Certification Information Degree: _______ License/Certification Type: ___________________________ License #: ____________ State Issued: ______________ Expiration Date: ___/___/____ DEA Number: ______________________ Medi-Cal PIN: ________________________ Medicare PTAN: ___________________________________ NPI number: ____________________ Taxonomy Code: ________________________ Signatures and Contact Information Employee Signature: _________________________________________________ Date: ______________ Employee Phone: ___________________ Employee E-mail: _________________________ Supervisor Name: _____________________Supervisor Signature: ____________________ Date: _______ Supervisor Phone: __________________ Supervisor E-mail: _________________________ Other staff to be notified of employee’s Staff ID# :________________________ E-mail:____________________
Additional Information: ___________________________________________________________________ DPH Compliance Office/Provider Relations Unit Only:
Staff ID#:________________
Credentialing Requirements Verified by: _____________________ Date: ___________________ DPH Compliance Office Revised 11/9/12
66
Hjfh;aksjd
City and County of San Francisco Department of Public Health
DPH COMPLIANCE OFFICE 1380 Howard St., 2nd Floor San Francisco, CA 94103
Attestation for Non-Licensed Staff and MAA Billing Staff Name: ________________________________________________________________________ Program Name: __________________________________ RU/Program Code: _____________________ Street Address: ___________________________ City: _____________________
State: ______
Zip Code: ___________ Agency Phone: _____________ Agency Fax: ____________ Supervisor Name: ____________________________
Title: _______________________________
MAA Billing privileges For Mental Health Graduate Student Trainee (e.g. individual participating in a field intern/trainee placement while enrolled in an accredited Masters in Social Work (MSW), Masters of Art (MA)/Masters of Science (MS) Counseling, PhD/PsyD training program.)
I attest that _____________________ (student) is a Graduate Student Trainee from ____________________, an accredited higher education institution, who began interning at our agency on _____/______/_______ (date). Internship will expire on ____/____
Mental Health Rehabilitation Specialist (MHRS)
I attest that _____________________ (staff) meets the requirements for an MHRS because of one of the following situations. Master’s Degree in a mental health related field and two (2) years experience in a mental health setting. OR Bachelor’s Degree in a mental health related field & four (4) years experience in a mental health setting. OR Associate Arts Degree in a mental health related field and six (6) years experience in a mental health setting. Mental Health Advocate and Other Staff not included in above categories I attest that _____________________ (staff) has graduated from High School or possess a GED. This staff person will be under my supervision and I will be responsible for oversight of their work at the agency. Substance Abuse Counselors who are not licensed, certified, or registered I attest that _____________________ (staff/student trainee) has begun employment/training/internship at the agency on _____/______/______ (start date) and that the staff/student trainee will become registered with a recognized certifying agency* within six (6) months of their start date. Supervisor Signature: ________________________ Title: _______________________ Date: __________ *Includes the following: American Academy of Health Care Providers in the Addictive Disorders Association of Christian Alcohol & Drug Counselors Board for Certification of Addiction Specialists Breining Institute California Association for Alcohol and Drug Educators California Association of Drinking Driver Treatment Programs
California Certification Board of Alcohol and Drug Counselors California Certification Board of Chemical Dependency Counselors Center for Criminality Addictions Research, Training, and Application Indian Alcoholism Commission of California, Inc
DPH Compliance Office Revised 11/9/12
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STEP-BY-STEP INSTRUCTIONS: Legibly PRINT OR TYPE responses. Your request will not be processed without an NPI number, supporting documentation, and both staff and supervisor signatures. Please submit your request two (2) weeks in advance. NO BILLING IS ALLOWED until verification and credentialing is finalized. NO RETROACIVE BILLING WILL BE ALLOWED.
VERIFICATION AND CERTIFICATION: Per the Office of Inspector General (OIG), and the California Department of Health Care Services (DHCS), counties are mandated to verify and certify individuals and/or organizational providers including contractors in their system MUST be checked against the OIG Exclusion List, the Medi-Cal List of Suspended or Ineligible Providers Lists, Licensing Boards, California Alcohol and Drug Programs (ADP) Certification/Registration lists, and the Excluded Parties List System prior to assigning Staff ID #s for documentation and billing, including MAA billing. The Department of Public Health (DPH) Compliance Office will be responsible for Verification and Certification. Verification will be done on a regular basis. PAGE 1 NEW STAFF ID: 1. 2. 3. 4.
Fill out CERTIFICATION AND VERIFICATION FOR STAFF ID form. Check box labeled *New Personal Information Box: Please fill in all information Program Information Box: For Substance Abuse Counselors who are CERTIFIED or REGISTERED, you MUST provide a copy of the CERTIFICATION or REGISTRATION. Fill in all other information. 5. License/Certification Information Box: For non-licensed PhD/PsyD (Post Doctorates) working towards their licensure, you must be waivered by the State. To become waivered, contact Jose Castro, DPH Compliance Office at 415255-3677 or email:
[email protected] For all other non-licensed staff, including PhD/PsyD that is not planning to obtain their professional license, you MUST also fill out the ATTESTATION FOR NON-LICENSED STAFF AND MAA BILLING form (page 2). Supervisor’s signature is mandatory. Please make sure that the name you fill in matches your license, NPI #, Medi-Cal PIN and/or Medicare PTAN #. 6. Signatures and Contact Information Box: It is mandatory that the employee and the employee’s supervisor sign this document. We will not be able to process this application without the employee and the supervisor’s signature. The email address for both the employee and supervisor is important. This is how we will notify you of the employee’s new Staff ID #.
DPH Compliance Office Revised 11/9/12
68
7. Additional staff that needs to be notified Box: Please fill in the name of any staff member from your agency that also needs to be notified of the employee’s Staff ID #. The email address is how they will be notified. 8. Fax this form(s) DIRECTLY to the IT ACCOUNTS COORDINATOR at (415) 252-3008 UPDATE(S): 1. Fill out CERTIFICATION AND VERIFICATION FOR STAFF ID form. 2. Check all box(es) appropriate to the information(s) that need to be updated in the system. 3. Write in your Staff ID #. 4. Personal Information Box: Please fill in all information including information that needs to be updated. 5. Program Information Box: For Substance Abuse Counselors who are CERTIFIED or REGISTERED and informing us of updates on your certification or registration, you MUST provide a copy of the CERTIFICATION or REGISTRATION. Fill in all other information. 6. License/Certification Information Box: Please fill in all information including information that needs to be updated. 7. Signatures and Contact Information Box: It is mandatory that the employee and the employee’s supervisor sign this document. We will not be able to process this application without the employee and the supervisor’s signature. The email address for both the employee and supervisor is important. This is how we will notify you of the employee’s new Staff ID #. 8. Additional staff that needs to be notified Box: Please fill in the name of any staff member from your agency that also needs to be notified of the employee’s Staff ID #. The email address is how they will be notified. 9. Fax this form(s) DIRECTLY to the DPH COMPLIANCE OFFICE at (415) 252-3032. PAGE 2 ATTESTATION FOR NON-LICENSED STAFF AND MAA BILLING FORM: Fill in all Personal Information and all other necessary information. Supervisor’s signature is mandatory. This form must accompany Page 1 if the staff is non-licensed. Failure to do so will hold up any processing. **PLEASE INFORM DPH COMPLIANCE OFFICE WHEN STAFF SEPARATES FROM YOUR AGENCY VIA FAX : FAX: (415) 252-3032
DPH Compliance Office Revised 11/9/12
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Section 6: Appendix C Avatar Service Codes for MENTAL HEALTH SERVICES
Avatar Code Service Code 90772 90801 90802 90804 90805 90806 90807 90808 90809 90810 90811 90812 90813 90814 90815 90846 90847 90849 90853 90857 90862 90875 90882 90885 90887 90889 96100 96105 96110 96111 96116 96118 97810 97813 99281 99282 99284 H0004DD
Service Definition
Service Code Definition Medication/Injection Psychiatric Diagnosis Interview exam Psych Diagnosis Inteview exam w/Interpreter Individual Psychotherapy 20-44 mins Individual Psych Eval & Mgmt 20-44 mins Individual Psychotherapy 45-74 mins Individual Psych Eval & Mgmt 45-74 mins Individual Psychotherapy 75+ mins Individual Psych Eval & Mgmt 75+ mins Individual Psychotherapy Interactive 20-44 mins Individual Psych Eval & Mgmt, Interactive 20-44 mins Individual Psychotherapy Interactive 45-74 mins Individual Psych Eval & Mgmt Interactive 45-74 mins Individual Psychotherapy Interactive 75+ mins Individual Psych Eval & Mgmt Interactive 75+ mins Family Psychotherapy w/o Client Present Family Psychotherapy w/Client Present Multi-Family Psychotherapy Group Psychotherapy Group Psychotherapy w/ Interpreter Medication Mgmt w/Brief Psychotherapy Biofeedback - Individual psychophysiological therapy Environmental Intervention Psychiatric Records Evaluation Interpret or Explain Psychiatric Info Psychiatric Report Preparation Psychological Testing w/Interpretation and Report Aphasia Assessment Developmental Testing, limited Developmental Testing, extended Neurobehavioral status exam Neuropsychological testing Acupuncture without electrical stimuli Acupuncture w/electrical stimuli Emergency Dept Visit, low to moderate severity Emergency Dept Visit, moderate severity Emergency Dept Visit, high severity Individual SA Counseling
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Section 6: Appendix C (cont.) Avatar Service Codes for MENTAL HEALTH SERVICES (cont.) 99284 H0004DD H0005DD H0036G H0036I H0046 H2010DB H2010GP H2010MN H2010MT H2011 H2011DB H2011N H2015AD H2015AL H2015AN H2015AP H2015PL H2015AS H2015CG H2015CI H2015CL H2015CN H2015GD H2015GN H2015GT H2015ID H2015IN H2015IT H2017I H2017G H2019 H2019A H2019C IPH2010 IPT1017 M0064 PHARM1 S9485 T1017
Emergency Dept Visit, high severity Individual SA Counseling Group SA Counseling Family Tx Group FTF Family Tx Individual FTF Collateral not Family or Guardian DBT Medication Support/Monitoring Medication - MH Rehab Group Svc Medication - Not Billable: Discontinued 9/1/2011 Medication Support/Monitoring Crisis Intervention DBT Crisis Intervention Crisis Intervention - Not Billable (DO NOT USE - always billable) DBT Assessment/TX Planning AB3632 Assessment with Language Differential Assessment - Not Billable (DO NOT USE - always billable) Plan Development AB3632 Plan Development w/Language Differential Assessment - Rehab Collateral - Group Rehab Collateral - Individual Rehab AB3632 Collateral w/Language Differential Collateral - Not Billable DBT Group Therapy Group Therapy - Not Billable Group Therapy - MH Rehab Svc DBT Individual Therapy Individual Therapy - Not Billable Individual Therapy - Rehab Individual MH Rehab Service Group MH Rehab Service Therapeutic Behavioral Health Svc 1:1 TBS Plan Development / Assessment TBS Collateral Medication Support in FFS Hospital Case Management in FFS Hospital Brief Medication Visit (Office/Clinic setting only) Phlebotomy Crisis Inter MH per diem Case Management Brokerage
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Section 6: Appendix C (cont.) Avatar Service Codes for MENTAL HEALTH SERVICES (cont.) T1017DB T1017N T1017AL T1017P T1017WC NMCMB NMIND NMCOL NMGRP NMMED ADM00 ADM10 ADM30 ADM50 ADM 70 ADM99
DBT Case Management Case Mgmt - Not Billable AB3632 Case Mgmt with Language Differential Case Mgmt for Placement, within 30 days of Discharge Wellness Check CM Case Management, Non-Billable IFSO Individual Therapy, Non-billable IFSO Collateral, Non-Billable IFSO Group Therapy, Non-Billable IFSO Medication Support, Non-Billable IFSO No Show Training MHP Staff Skills/Knowledge Attempted Visit Life Support/Board & Care Transportation Admin Note, Not Billed, No Productivity
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Section 6: Appendix D Correcting Service Posting: Edit Service Information
Introduction This option is used to edit the service information for posted services regardless of entry option (i.e. Progress Note, Client Charge Input, Worklist, Appointment Post Activity Log, etc.). Use “edit service information” to make changes. One or more services can be edited in an open status. Changes will immediately reflect in the client treatment service history. Menu tree: Services→ Ancillary/Ambulatory Services→ Edit Service Information 1. In “Client ID” field, type in client ID or LastName,FirstName. Click on “Process Search” button to activate search. Page 2 of 6 Copyright © 1997-2010 Netsmart New York Inc. All rights reserved. This document contains pro2. Select the client you wish to edit services for. The ID or Name will result in a selection from a pop up window if only one client meets search criteria:
Or if more than one client meets search criteria, a drop down will appear:
3. In “Episode Number” field, select the episode where the service is liability resides. 4. In “Service Start Date” field, type in the start date (MM/DD/YYYY) for initial date of service. Or select “T” for today’s date ; “Y” for yesterday’s date. 5. In “Service End Date” field, type in the start date (MM/DD/YYYY) for initial date of service. Or select “T” for today’s date ; “Y” for yesterday’s date. 6. In “Service Selection Default” field, select either “All” or “None”. This will place a default check box in the “Select Service(s) to Edit” screen if “All” is selected. Selecting “All” will make changes to every service that are similar such as location. 7. Click on the “Select Service(s) to Edit” button to view services for editing. Page 3 of 6 Copyright © 1997-2010 Netsmart New York Inc. All rights reserved. This document contains proprietary and confidential information of Netsmart New York Inc.
Note: The form “BH7019” is used for void and replace for both Mental Health and Substance Abuse Services
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Section 6: Appendix E
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Section 6: Appendix F Day Rehabilitation Services Day Rehabilitation, California Code of Regulation, Title 9, Section 1810.212 “Day Rehabilitation” means a structured program of rehabilitation and therapy to improve, maintain or restore personal independence and functioning, consistent with requirements for learning and development, which provides services to a distinct group of individuals. Services are available at least three 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. HCPCS H2012FD – Day Treatment Rehabilitation, Full Day H2012RH – Day Treatment Rehabilitation, Half Day H2012TG – Day Treatment Intensive, Full Day H2012HD – Day Treatment Intensive, Half Day
HCPCS H2012RF – Non-Billable Day Treatment Rehabilitation, Full Day H2012RN – Non-Billable Day Treatment Rehabilitation, Half Day H2012IF – Non-Billable Day Treatment Intensive, Full Day H2012IN – Non-Billable Day Treatment Intensive, Half Day
Staffing Requirements Day Rehabilitation can be provided as a full day or half day service. Full day programs must last more than four hours per day. Half day programs must last more than 3 hours per day. State DHCS documentation standards for Day Rehabilitation require a weekly summary of the client’s attendance, service activities and progress on goals during the program. All staff will use HCPCS codes for coding this service as there is no comparable CPT code.
At a minimum, there must be an average ratio of at least one person from the following list providing Day Rehabilitation services to ten beneficiaries or other clients in attendance during the period the program is open. (1) Physicians. (2) Psychologists or related waived/registered professionals. (3) Licensed Clinical Social Workers or related waived/registered professionals. (4) Marriage, Family and Child Counselors or related waived/registered professionals. (5) Registered Nurses. (6) Licensed Vocational Nurses. (7) Psychiatric Technicians. (8) Occupational Therapists. (9) Mental Health Rehabilitation Specialists. Persons who are not solely used to provide Day Rehabilitation services may be utilized according to program need, but shall not be included as part of the above ratio formula. The MHP shall ensure that there is a clear audit trail of the number and identity of the persons who provide Day Rehabilitation services and function in other capacities. Persons providing services in Day Rehabilitation programs serving more than 12 clients shall include at least two of the following: (1) Physicians. (2) Psychologists or related waived/registered professionals. (3) Licensed Clinical Social Workers or related waived/registered professionals. (4) Marriage, Family and Child Counselors or related waived/registered professionals. (5) Registered Nurses. (6) Licensed Vocational Nurses. (7) Psychiatric Technicians. (8) Mental Health Rehabilitation Specialists.
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Section 6: Appendix F Day Rehabilitation Services cont. Additional Staffing Requirements (a) Staffing ratios must be consistent with the requirements in Title 9, CCR, Section 1840.352. (b) The average ratio of day rehabilitation program staff to attendees is based on the average number of day rehabilitation program attendees (Medi-Cal beneficiaries and other clients) participating in the continuous hours of operation of the day treatment program on that day. (c) When day rehabilitation programs provide services in multiple rooms, each offering a different milieu, staff counted in the staffing ratio would have to be of the appropriate number to meet the staffing ratio requirements for the given beneficiaries or clients in the overall program. (d) Staff counted in ratios must be present and available for the provision of the day rehabilitation program. This means they must be: ➢➢ Available to the therapeutic milieu And ➢➢ Available to respond to the needs of the group (e) Staff providing individual services to day rehabilitation program attendees may continue to be counted in the staffing ratio during the time they are providing individual services in addition to the time they are present and available in the therapeutic milieu. (f) Day program staff in the milieu room working momentarily with an individual beneficiary would be considered staff available to the milieu. (g) Day program staff on site, but in another room performing administrative activities or any activities other than individual treatment services that are part of the day program, staff waiting in a separate area, and staff on call would not be considered staff available to the therapeutic milieu. (h) At least one day treatment staff person must be physically present in any room or other separately identifiable location in which the therapeutic milieu is being provided to one or more clients. This staff person does not have to be of the staff described in Title 9, CCR, Section 1840.352, if the staff meeting these criteria are outside the milieu under the following allowable conditions: ➢➢ Providing individual services to day rehabilitative program attendees ➢➢ Attending to immediate personal needs ➢➢ Attending to a crisis situation (i) Remaining staff must have adequate training, knowledge and skill to continue the day treatment program,
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Section 6: Appendix F Day Rehabilitation Services cont. Service Components In addition to meeting the requirements of Title 9, CCR, Sections 1840.330 and 1840.352, providers of day rehabilitation must include the following minimum service components: (a) Community meetings: 1. Occur a minimum of once per day, but may occur more frequently. 2. Address issues pertinent to the continuity and effectiveness of the therapeutic milieu 3. May, but are not required to, be part of the continuous therapeutic milieu 4. Actively involve staff and clients 5. Include a staff person who is a physician, a licensed/registered/waived , clinical social worker, or marriage and family therapist, a registered nurse, a psychiatric technician, a licensed vocational nurse, or a mental health rehabilitation specialist. 6. Address relevant items including, but not limited to: •
the daily schedule,
•
current events,
•
individual issues brought by clients or staff,
•
conflict resolution within the milieu,
•
planning for the day, the week, or special events,
•
old business from previous meetings or from previous day treatment experiences
7. Debriefing or wrap-up (b) A therapeutic milieu: 1. A therapeutic program structured by the required service components listed below with specific activities performed by identified staff. 2. Occurs for the continuous scheduled hours of operation for the program: •
More than four hours for a full-day program
•
A minimum of three hours for a half-day program
3. Includes staff and activities that teach, model and reinforce constructive interactions 4. Includes peer and staff feedback to clients on: •
strategies for symptom reduction,
•
increasing adaptive behaviors
•
reducing subjective distress
5. Involves clients in the overall program by providing opportunities to lead community meetings and to provide feedback to peers 6. Includes behavior management interventions that focus on teaching self-management skills that clients may use to control their own lives, to deal effectively with present and future problems, and to function well with minimal or no additional therapeutic intervention.
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Section 6: Appendix F Day Rehabilitation Services cont. Service Components (Continued) (c) The following required activities must be available during the course of the therapeutic milieu for at least a weekly average of three hours per day for full-day programs and two hours per day for half-day programs: 1. Skill Building Groups -- Staff help clients: ▶▶ Identify psychological barriers ▶▶ Identify skills to address symptoms and behaviors ▶▶ Increase adaptive behaviors. 2. Adjunctive Therapies -- Non-traditional therapies that use self expression such as art, recreation, dance and music as the therapeutic intervention in order to develop or enhance skills related to client goals. Process Groups -- Staff-facilitated groups that use group process to help clients develop the skills necessary to manage their individual problems and issues by providing peer interaction and feedback in developing problem-solving strategies and resolving behavioral and emotional problems. (d) Psychotherapy -- Day rehabilitation may include psychotherapy instead of or in addition to process groups. Psychotherapy is the use of psychosocial methods to help the client(s): ▶▶ Achieve a better psychosocial adaptation ▶▶ Acquire greater human realization of psychosocial potential and adaptation ▶▶ Modify internal and external conditions affecting behavior, emotions, and thought with respect to both intrapersonal and interpersonal processes. Psychotherapy must be provided by licensed, registered, or waived staff practicing within their scope of practice and does not include physiological interventions such as medication. (e) An established mental health crisis protocol. The protocol: 1. Must assure the availability of appropriately trained and qualified staff and include agreed upon procedures for addressing crisis situations. 2. May include referrals for crisis intervention, crisis stabilization, or other specialty mental health services necessary to address the client’s urgent or emergency psychiatric condition. 3. If clients will be referred out for crisis services, the day rehabilitation program must demonstrate that program staff have the capacity to handle the crisis until the client is linked to the outside service. (f) A detailed weekly schedule indicating when and where the service components will be provided, and by whom and that specifies the program staff, their qualifications, and their scope of responsibility. The weekly schedule must be available to clients and, as appropriate, to their families, caregivers, or significant support persons. (g) Documentation of a clear audit trail and staff responsibilities including specific times staff are providing day rehabilitation services exclusive of other activities for any day rehabilitation staff with other responsi bilities (e.g. as group home staff, school staff or other treatment program staff). (h) A written program description that describes the specific activities of the service reflecting the required components.
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Section 6: Appendix F Day Rehabilitation Services cont. Contact and Site Requirements The beneficiary will be present for all scheduled hours of operation each day. When a beneficiary is unavoidably absent for some portion of the hours of operation, the provider will receive Medi-Cal reimbursement for day rehabilitation services only if the beneficiary is present for at least 50 percent of the scheduled hours of operation for that day. At least one contact per month (face-to-face or by an alternative method such as e-mail or telephone) must occur with the legally responsible adult for a minor client. The contact(s) should focus on the role of the significant support person in supporting the client’s community reintegration. It is expected that this contact will occur outside hours of operation and the therapeutic milieu. The requirement for continuous hours of operation does not preclude short breaks (for example, a school recess period) between milieu activities. A lunch or dinner break may also be appropriate, depending on the program’s schedule. These breaks do not count toward the total hours of operation of the day program for purposes of determining minimum hours of service.
Authorization Requirements Day Treatment Rehabilitation Services must be pre-authorized by SFDPH, Community Programs every six months. If additional mental health services are needed, prior authorization is required if they are to be provided on the same day as Day Rehabilitation. Lockouts for Day Rehabilitation Day Rehabilitation is not reimbursable under the following circumstances: (1) When Crisis Residential Treatment Services, Psychiatric Inpatient Hospital Services, Psychiatric Health Facility Services, or Psychiatric Nursing Facility Services are reimbursed, except for the day of admission to those services. (2) Mental Health Services are not reimbursable when provided by Day Rehabilitation staff during the same time period that Day Rehabilitation is provided. (3) Two half-day programs may not be provided to the same beneficiary on the same day.
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Section 6: Appendix F Day Treatment Intensive Services Day Treatment Intensive, California Code of Regulation, Title 9, Section 1810.213 “Day Treatment Intensive” means a structured, multi-disciplinary program of therapy which may be an alternative to hospitalization, avoid placement in a more restrictive setting, with services available at least three hours and less than twenty-four hours each day the program is open. Service activities may include, but are not limited to, assessment, plan development, therapy, rehabilitation and collateral. H2012TG – Day Treatment Intensive, Full Day H2012HD – Day Treatment Intensive, Half Day Day Treatment Intensive can be provided as a full day or half day service. Full day programs must last more than four hours per day. Half day programs must last more than 3 hours per day. CCR, Title 9 documentation standards for Day Treatment Intensive require a daily progress note and a weekly summary of the client’s attendance, service activities and progress on goals during the program.
Staffing Requirements At a minimum, there must be an average ratio of at least one person from the following list providing Day Treatment Intensive services to eight beneficiaries or other clients in attendance during the period the program is open. 1. Physicians. 2. Psychologist or related waived/registered professionals. 3. Licensed Clinical Social Workers or related waived/registered professionals. 4. Marriage, Family and Child Counselors or related waived/registered professionals. 5. Registered Nurses. 6. Licensed Vocational Nurses. 7. Psychiatric Technicians. 8. Occupational Therapists. 9. Mental Health Rehabilitation Specialists. Persons who are not solely used to provide Day Treatment Intensive services may be utilized according to program need, but shall not be included as part of the above ratio formula. The provider shall ensure that there is a clear audit trail of the number and identity of the persons who provide Day Treatment Intensive services and function in other capacities. Persons providing services in Day Treatment Intensive programs serving more than 12 clients shall include at least one person from each of two of the following groups: 1. Physicians. 2. s or related waived/registered professionals. 3. Licensed Clinical Social Workers or related waived/registered professionals. 4. Marriage, Family and Child Counselors or related waived/registered professionals.. 5. Registered Nurses. 6. Licensed Vocational Nurses. 7. Psychiatric Technicians. 8. Occupational Therapists. 9. Mental Health Rehabilitation Specialists.
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Section 6: Appendix F Day Treatment Intensive Services cont. Service Components In addition to meeting the requirements of Title 9, CCR, Sections 1840.318, 1840.328, and 1840.350, providers of day treatment intensive must include the following minimum service components: (a)
(b)
1. 2. 3. 4. 5. 6.
Community meetings: Occur a minimum of once per day, but may occur more frequently. Address issues pertinent to the continuity and effectiveness of the therapeutic milieu May, but are not required to, be part of the continuous therapeutic milieu Actively involve staff and clients Include a staff person whose scope of practice includes psychotherapy Address relevant items including, but not limited to: • the daily schedule, • current events, • individual issues brought by clients or staff, • conflict resolution within the milieu, • planning for the day, the week, or special events, • old business from previous meetings or from previous day treatment experiences
A therapeutic milieu: 1. A therapeutic program structured by the required service components with specific activities performed by identified staff. 2. Occurs for the continuous scheduled hours of operation for the program: • More than four hours for a full-day program • A minimum of three hours for a half-day program 3. Includes staff and activities that teach, model and reinforce constructive interactions 4. Includes peer and staff feedback to clients on: • strategies for symptom reduction, • increasing adaptive behaviors • reducing subjective distress 5. Involves clients in the overall program by providing opportunities to lead community meetings and to provide feedback to peers 6. Includes behavior management interventions that focus on teaching self-management skills that clients may use to control their own lives, to deal effectively with present and future problems, and to function well with minimal or no additional therapeutic intervention.
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Section 6: Appendix F Day Treatment Intensive Services cont. (c)
The following required activities must be available during the course of the therapeutic milieu for at least a weekly average1 of three hours per day for full-day programs and two hours per day for half-day pro- grams: 1. Skill Building Groups -- Staff help clients: ▶▶ identify psychological barriers ▶▶ identify skills to address symptoms and behaviors ▶▶ increase adaptive behaviors. 2. Adjunctive Therapies -- Non-traditional therapies that use self expression such as art, recreation, dance and music as the therapeutic intervention in order to develop or enhance skills related to client goals. 3. Psychotherapy -- The use of psychosocial methods to help the client(s): ▶▶ Achieve a better psychosocial adaptation ▶▶ Acquire greater human realization of psychosocial potential and adaptation ▶▶ Modify internal and external conditions affecting behavior, emotions, and thought with respect to both intrapersonal and interpersonal processes. Psychotherapy must be provided by licensed, registered, or waived staff practicing within their scope of practice and does not include physiological interventions, such as medication. (d) (e)
Process Groups -- Day Treatment Intensive may also include staff-facilitated process groups that use group process to help clients develop the skills necessary to manage their individual problems and issues by providing peer interaction and feedback in developing problem-solving strategies and resolving be- havioral and emotional problems. An established mental health crisis protocol. The protocol: 1. Must assure the availability of appropriately trained and qualified staff and include agreed upon proce dures for addressing crisis situations. 2. May include referrals for crisis intervention, crisis stabilization, or other specialty mental health services necessary to address the client’s urgent or emergency psychiatric condition. 3. If clients will be referred out for crisis services, the Day Treatment Intensive program must demonstrate that program staff have the capacity to handle the crisis until the client is linked to the outside service.
(f)
A detailed weekly schedule indicating when and where the service components will be provided, and by whom and that specifies the program staff, their qualifications, and their scope of responsibility. The weekly schedule must be available to clients and, as appropriate, to their families, caregivers, or signifi cant support persons. Documentation of a clear audit trail and staff responsibilities including specific times staff are providing day treatment intensive services exclusive of other activities for any day treat ment intensive staff with other responsibilities (e.g. as group home staff, school staff or other treatment program staff).
(g) A written program description that describes the specific activities of the service reflecting the required components. 1
For example, a full day program that operates five days per week would need to provide a total of 15 hours for the week while a full day program that operates seven days per week would need to provide a total of 21 hours for the week.
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Section 6: Appendix F Day Treatment Intensive Services cont. Contact and Site Requirements The beneficiary will be present for all scheduled hours of operation each day. When a beneficiary is unavoidably absent for some portion of the hours of operation, the provider will receive Medi-Cal reimbursement for day treatment intensive services only if the beneficiary is present for at least 50 percent of the scheduled hours of operation for that day. At least one contact per month (face-to-face or by an alternative method such as e-mail or telephone) must occur with the legally responsible adult for a minor client. The contact(s) should focus on the role of the significant support person in supporting the client’s community reintegration. It is expected that this contact will occur outside hours of operation and the therapeutic milieu. The requirement for continuous hours of operation does not preclude short breaks (for example, a school recess period) between milieu activities. A lunch or dinner break may also be appropriate, depending on the program’s schedule. These breaks do not count toward the total hours of operation of the day program for purposes of determining minimum hours of service.
Authorization Requirements Day Treatment Intensive Services must be authorized by SFDPH, Community Programs every three months. If additional mental health services and medication support services are needed, prior authorization is required if they are to be provided on the same day as Day Treatment Intensive. Lockouts for Day Treatment Intensive Day Treatment Intensive is not reimbursable under the following circumstances: (a) When Crisis Residential Treatment Services, Psychiatric Inpatient Hospital Services, Psychiatric Health Facility Services, or Psychiatric Nursing Facility Services are reimbursed, except for the day of admission to those services. (b)
Mental Health Services are not reimbursable when provided by Day Treatment Intensive staff during the same time period that Day Treatment Intensive is provided. If authorized, Medication Support Services and case management services may be provideded during Day Treatment program hours.
*Day Treatment services may also be billed on the date of discharge, if the client attended at least 50% of the Day Treatment
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Section 6: Appendix F Adult Residential Treatment Services (Transitional and Long Term) Definition (§1810.203): “Adult Residential Treatment Service” means rehabilitative services, provided in a noninstitutional, residential setting, for beneficiaries who would be at risk of hospitalization or other institutional placement if they were not in the residential treatment program. The service includes a range of activities and services that support beneficiaries in their efforts to restore, maintain and apply interpersonal and independent living skills and to access community support systems. The service is available 24 hours a day, seven days a week. Service activities may include but are not limited to assessment, plan development, therapy, rehabilitation and collateral. Service Activities: Services shall be consistent with §532 of Title 9, California Code of Regulations. Service activities may include Assessment, Plan Development, Therapy, Rehabilitation and Collateral (§1810.203). NOTE: √ Not all of these activities need to be provided for the service to be billable. √ Medication Support Services shall be billed separately from Adult Residential Treatment Services [§1840.326(b)]. The codes for claiming are according to type of residential program. Please refer to "Avatar Procedure Codes" for the appropriate code(s), code modifiers, and place of service codes for: Transitional Residential - Transitional Transitional Residential - Long Term GENERAL RULES Service Reimbursement by Calendar Days (§1840.320): This applies to: Adult Residential Treatment Services (Transitional and Long-Term) Crisis Residential Treatment Services Psychiatric Health Facility Services Claiming Rules (§1840.320): The following requirements apply for claiming of services based on calendar days: (1) A day shall be billed for each calendar day in which the client receives face-to-face services and the client has been admitted to the program. Services may not be billed for the days the client is not present. (2) Board and Care costs are not included in the claiming rate (also §1840.312). (3) The day of admission may be billed but not the day of discharge.
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Adult Residential Treatment Services (cont’d) Minimum Documentation Requirements: (See also SFDPH, Community Programs for general documentation rules) ⇒ Date(s) of Service ⇒ Procedure Code ⇒ Written assessment upon admission that includes: health and psychiatric histories; psychosocial skills; social support skills; current psychological, educational, vocational and other functional limitations; medical needs, as reported; and meal planning, shopping, and budgeting skills. ⇒ The notes shall address: (a) Activities in which the client participated, (b) Client's behaviors and staff intervention, (c) Progress toward objectives or documentation of lack of progress, (d) Involvement of family members, if appropriate, (e) Contact with other programs/agencies/treatment personnel involved with the client's treatment. ⇒ There shall be notes for all staff involved in the client's treatment. ⇒ For Crisis Residential and Transitional and Long-Term Residential services: (a) There shall be a note whenever a scheduled session takes place with the client. (b) There shall be a note indicating the activities in which the client participated. Site and Contact Requirements (§1840.332): (a) Adult Residential Treatment Services shall have a clearly established certified site for services, although all services need not be delivered at that site. Services shall not be claimable unless there is face-to-face contact between the beneficiary and a treatment staff person of the facility on the day of service and the beneficiary has been admitted to the program. (b) Programs that provide Adult Residential Treatment Services must be certified as a Social Rehabilitation Program by the Department as either a Transitional Residential Treatment Program or a Long Term Residential Treatment Program in accordance with Chapter 3, Division 1, of Title 9. Facility capacity must be limited to a maximum of 16 beds. (c) In addition to Social Rehabilitation Program certification, programs which provide Adult Residential Treatment Services must be licensed as a Social Rehabilitation Facility or Community Care Facility by the State Department of Social Services in accordance with Chapters 1 and 2, Division 6, of Title 22 or authorized to operate as a Mental Health Rehabilitation Center by the Department in accordance with Chapter 3.5, Division 1, of Title 9, beginning with Section 51000.
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Adult Residential Treatment Services (cont’d) Lockouts (§1840.362): Adult Residential Treatment Services are not reimbursable under the following circumstances: (a) When Crisis Residential Treatment Services, Psychiatric Inpatient Hospital Services, Psychiatric Health Facility, or Psychiatric Nursing Facility Services are reimbursed, except for the day of admission. (b) When an organizational provider of both Mental Health Services and Adult Residential Treatment Services allocates the same staff’s time under the two cost centers of Mental Health Services and Adult Residential Treatment Services for the same period of time. Frequency of Documentation: At least a weekly summary and a separate note whenever a scheduled session takes place with the client. Staffing Ratio and Staff Qualifications (§1840.354): (a) Staffing ratios and qualifications in Adult Residential Treatment Services shall be consistent with Title 9, §531(b) and (c) (b) There is a clear audit trail of the number and identity of the persons who provide Adult Residential Treatment Services and function in other capacities.
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Section 6: Appendix G Included and Excluded Diagnoses Included Diagnoses o Pervasive Developmental Disorders (except Autism) o Disruptive Behavior & Attention Deficit Disorders o Feeding & Eating Disorders o Elimination Disorders
o Disorders of Infancy, Childhood
o Schizophrenia & other Psychotic Disorders o Mood Disorders
o Anxiety Disorders
o Somatoform Disorders o Factitious Disorders
o Dissociative Disorders o Paraphilias
o Gender Identity Disorders
o Impulse Control Disorders o Adjustment Disorders
o Personality Disorders (18 years old or older)
o Medication-Induced Movement Disorders related to other included diagnoses Excluded Diagnoses o Mental Retardation o Learning Disorders
o Communication Disorders
o Autistic Disorder, Other Pervasive Developmental Disorders
o Delirium, Dementia, and Amnestic and Other Cognitive Disorders o Mental Disorders due to a General Medical Condition o Substance-Related Disorders o Sexual Dysfunctions o Sleep Disorders
o Antisocial Personality Disorders o Tic Disorders o V-Codes
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Section 6: Appendix H
88
Section 6: Appendix I
San Francisco Community Behavioral Health Services Standardized Abbreviations Abbreviation 24/7 A ā @ A/H A/O AA ABD ACT AD ADA ADD ADHD ADL ADM ADP ADU ADMIN ADOL ADV DIR AIDS AKA ALOC AM AMA AMPHET AMS AMT. ANSA A/OA AOD A/P APA APP APPROP APPT APROX APS ASA ASAM ASAP
Definition 24 Hours A Day/Seven Days A Week Before At Auditory Hallucinations Alert & Oriented Alcoholics Anonymous Abdomen Assertive Community Treatment Team Alzheimer’s disease Americans with Disabilities Act Attention Deficit Disorder Attention Deficit Hyperactivity Disorder Activities of Daily Living Admission California State Office of Alcohol and Drug Programs Acute Diversion Unit Administrative Adolescent Advance Directive Acquired Immune Deficiency Syndrome Also Known As Altered Level Of Consciousness Morning Against Medical Advice or American Medical Association Amphetamines Acute Mental Status (on emergency room records) Amount Adult Needs and Strength Assessment Adult/Older Adult Services Alcohol and Other Drugs Assessment / Plan American Psychiatric Association Aid Paid Pending Appropriate(ly) Appointment Approximate(ly) Adult Protective Service Aspirin American Society of Addiction Medicine As Soon As Possible
92
ASI ASSESS ASW ATOD ATTN AVG Ax AWOL B BA BAC B&B B&C BDI BDZ BEH BF BHAC BHBIS BHVP BIB BIBA bid Bipolar BM BOCC BP BPD bro b/t Bup Bup/nx BX C c C/O CA CAADAC CAAP CAADE CAD CADC I / II CADE CAFAS CAGE CalOMS CANS CAP
Addiction Severity Index Assessment Associate of Social Work (registered with Board) Alcohol, Tobacco, and Other Drugs Attention: Average Auxiliary Absence With Out Leave Bachelor of Arts Blood Alcohol Content Bowel & Bladder Board & Care Beck Depression Inventory Benzodiazepine Behavior Boyfriend Behavioral Health Access Center Behavioral Health Billing Information Systems Bayview Hunters Point Mental Health Brought in By Brought In By Ambulance Twice a day Bipolar Affective Disorder Bowel Movement Business Office Contract Compliance Blood Pressure Borderline Personality Disorder Brother Between Buprenorphine Buprenorphine/Naloxone (Subonoxe) Behavior with Complains of Cancer California Association of Alcoholism and Drug Abuse Counselors County Adult Assistance Program California Association of Alcohol and Drug Educators Coronary Artery Disease Certified Alcohol and Drug Counselor Certified Alcohol and Drug Educator Child and Adolescent Functional Assessment Scale Alcoholism Screening Tool California Outcome Measurement System Children and Adolescent Needs and Strengths Assessment Capsule
CAUC CBC CBHS CBO CBT CBZ CCBADC CCDC CCISC CCS CCSF CD CDC CDTA CDTA PM CERT CHEMO CHF CHP CHN CIGS CIR CIWA CLT CM CMS CNS CP CTF CTNB COD COLL COMPASS CONC CONS CON REP PROG cont. COORD COPD COPE CORRESP CPR CPS CPT CQI CRDC Crisis Res.
Caucasian Complete Blood Count Community Behavioral Health Services Community Based Organization Cognitive Behavioral Therapy Carbamazepine California Certification Board of Alcohol and Drug Counselors Chinatown Child Development Center Comprehensive, Continuous, Integrated System of Care Comprehensive Crisis Services (umbrella organization for Child Crisis, Crisis Response, and Mobile Crisis) City and County of San Francisco Chemical Dependency Center for Disease Control Contract Development and Technical Assistance Contract Development and Technical Assistance Program Manager Certification Chemotherapy Congestive Heart Failure Community Health Programs Community Health Network Cigarettes Critical Incident Review Clinical Institute Withdrawal Assessment Client Case management Center for Medicare & Medicaid Services Central Nervous System Community Programs Community Treatment Facility Chinatown North Beach Co-Occurring Disorders Collateral Co-Morbidity Program Audit Self-Survey Concentrate Conserved / Conservatorship Conditional Release Program Continuously Coordinate Chronic Obstructive Pulmonary Disease Centralized Opiate Placement Evaluation Correspondence Cardiopulmonary Resuscitation Children Protective Services Current Procedural Terminology Code (billing) Continuous Quality Improvement Cost Report Data Collection Crisis Residential
CRS CRT CRAFFT CSA CSAT CSI CSOC CSU CT or CAT CVA CWW Cx CXR CYF D DA DAU / DTR DAY TX DBT D/C DC DHCS DD dec DEL DETOX DIFF DIR DISPO DIV DM DME DMC DMH DMV DNR DO d.o.a DOB d.o.e. d.o.s DPH Dr DSM DT’s DUI DUR DV
Crisis Response Service Crisis Resolution Team Substance Abuse Screening Tool For Child And Youth Client Service Authorization Center for Substance Abuse Treatment Computerized Screening Incorporated Children’s System of Care Crisis Stabilization Unit Computerized Tomography Cerebrovascular Accident Child Welfare Worker Crisis Chest X-Ray Child, Youth, and Family Dopamine Daughter Day Treatment Dialectic Behavior Therapy Discharge Discontinue Department of Health Care Services Developmentally Disabled Decanoate Delusions Detoxification Differential Director Disposition Divorce Diabetes Mellitus Durable Medical Equipment Drug Medi-Cal Department Of Mental Health Department of Motor Vehicles Do Not Resuscitate Doctor of Osteopathic Medicine/Physician Date of Admission Date of Birth Date of Entry Date of Service Department of Public Health Doctor Diagnostic & Statistical Manual Delirium Tremens Driving Under the Influence Drug Utilization Review Domestic Violence
Dx Dz E EAP ECG ECT ED EDUC EEG EENT e.g. EHR EKG & ECG Elix. EMDR EMT EPS EPSDT EQRO ER ESP ETA EtOH Ext. EVAL E.W. F F/U fa FAS FBS FCMHP Fe FG FL FMP FNP FOI FQHC FREQ FSA Fx FY G GA GABA GAD GAF
Diagnosis Disease Employee Assistance Program Echocardiogram Electro Convulsive Therapy Emergency Department Educate / Education Electroencephalogram Eyes, ears, nose, and throat (L. exempli gratia) for example Electronic Health Record Electro cardiogram Elixir Eye Movement Desensitization Reintegration Emergency Medical Technician Extrapyramidal Side Effects Early & Periodic Screening, Diagnosis and Treatment External Quality Review Organization Emergency Room Especially Estimated Time of Arrival Alcohol Extract Evaluation Eligibility Worker Follow Up Father Fetal Alcohol Syndrome Fasting Blood Sugar Foster Care Mental Health Program Iron Fasting Glucose Fluid Family Mosaic Project Family Nurse Practitioner Flight of Ideas Federally Qualified Health Center Frequent Family Service Agency Fracture Fiscal Year General Assistance Gamma Aminobutyric Acid General Anxiety Disorder Global Assessment of Functioning
GD GERD Gfa / GF G/F GHB GI GLBTQQ glu gm Gmo / GM GP Gr Group Tx GRP(s) G/W GSW gtt. GU GYN H H HA H2O H&P Hal / Halluc 5 HT 5HT2 h.s. H/I HBP HBV Hct HCV HF / HC / HW HEENT Hep Hgb HIE HIM HIPAA HIV HMO HOH Hosp HPI HPV hr. HR
Gravely Disabled Gastro Esophageal Reflux Disease Grandfather Girlfriend Gamma Hydroxybutyrate Gastrointestinal Gay, Lesbian, Bisexual, Transgendered, Queer, Questioning Glucose Gram Grandmother General Practitioner Grains Group Therapy Group(s) Glucose and Water Gunshot Wound Drop Genitourinary Gynecology Heroin Headache Water History and Physical Hallucinations Serotonin Serotonin 2 Receptor Hour of sleep/bedtime Homicidal Ideation High Blood Pressure Hepatitis B Hematocrit Hepatitis C Healthy Families/ Healthy Children/ Healthy Workers Head, ears, eyes, nose & throat Hepatitis Hemoglobin Health Information Exchange Health Information Management Health Insurance Portability & Accountability Act Human Immunodeficiency Virus Health Maintenance Organization Hard of Hearing Hospital / Hospitalized History of Present Illness Human Papilloma Virus Hour Human Resources
H.R. HRSA HAS ht. HTN HUH HUSB HV Hx / H/O I I&O IAPC ICD ICU IDDM IDDT IEP IISC ILSA IM IMD Incont. IN-PT IPT ISC IT ITWS IV IVDU J JCAHO JC JJC JPS JUV K K+ Kcal Kg. L LAB LANG LT LB or lb. LCR LCSW LD LDL
Heart Rate Health Resources and Services Administration Human Services Agency Height Hypertension Housing Urban Health Husband Home Visit History / History of Intake and Output Interagency Placement Committee International Classification Disorder Intensive Care Unit Insulin Dependent Diabetes Mellitus Integrated Dual disorder Treatment Individual Education Plan Interagency Intensive Services Committee Integrated Longitudinal Strength-Base Assessment Intramuscular Institute of Mental Disease Incontinent Inpatient Intensive Placement Team Integrated Service Center Information Technology Information Technology and Web Services Intravenous Intravenous Drug Use Joint Commission on Accreditation of Health Care Organizations Junior College Juvenile Justice Center Jail Psychiatric Services / Juvenile Probation Services Juvenile Potassium Kilo Calorie Kilogram Laboratory Language Left Pound Lifetime Clinical Record Licensed Clinical Social Worker Learning Disability Low Density Lipoprotein
L-Fac LFU LG LiCo3/Li LLE LLQ LMFT LMP LOA LOC LOCUS LOS LP LPN LPT LPPI LPS LSD L-SNF LTC LUE LUQ LVN M MAOI M MA MAA Marital Status MAST MAT MAX MCAH MCTT Mcg MCI MD MDD MDMA MDO MEDI-MEDI mEq MED HX Meds MFT
Locked Facility Legal Entity File Update Large Lithium Carbonate Left Lower Extremity Left Lower Quadrant Licensed Marriage and Family Therapist Last Menstrual Period Leave of Absence Loss of Consciousness Level of Care Utilization System Length of Stay Lumbar Puncture Licensed Practical Nurse Licensed Psychiatric Technician Langley Porter Psychiatric Institute Lanterman-Petris-Short Lysergic Acid Diethylamide Locked Skilled Nursing Facility Long Term Care Left Upper Extremity Left Upper Quadrant Licensed Vocational Nurse Monoamine Oxidase Inhibitors Male Masters of Arts or Medical Assistant Medi-Cal Administrative Activities D Divorced M Married S Single W Widowed Michigan Alcohol Screening Test Medication Assisted Treatment Maximum Maternal Child Adolescent Health Mobile Crisis Treatment Team Microgram McAuley Adolescent Institute or Mild Cognitive Impairment Medical Doctor/Physician Major Depressive Disorder Methylenedioxymethamphetamine (Ecstasy) Mentally Disordered Offender Medi-Cal and Medicare Milliequivalents Medical History Medications Marriage & Family Therapist
MFTI mg M GR MH MHA MHP MHRC MHRS MHSA MHSIP MHTC MHW MI MIDAS MIN Mission ACT Mission PPN MJ ml MMPI MMSE MMT mo MOCD MOM MOW MRI MRS MSE M.S. MSG MST MSW MTG MVA N N/A NA Na NAC NAMI NARC NAS NASW N/C NCADA
Marriage & Family Therapist Intern Milligram Maternal Grandmother Mental Health Mental Health Assistant Mental Health Plan Mental Health Rehabilitation Center Mental Health Rehab Specialist Mental Health Services Act or Prop 63 Mental Health Statistics Improvement Program Mental Health Treatment Center Mental Health Worker Myocardial Infarction or Motivational Interviewing or Motivational Incentives Mental Illness Drug and Alcohol Screening Minutes Mission Assertive Community Treatment Mission Private Provider Network Clinic Marijuana Milliliter Minnesota Multiphasic Personality Inventory Mini-Mental State Exam Methadone Maintenance Treatment Mother Mayor’s Office of Community Development Milk of Magnesia Meals On Wheels Magnetic Resonance Imaging Monitoring Report Summary Mental Status Exam Master of Science Degree Message Multisystemic Therapy Masters of Social Work (not registered with Board) or Medically Supervised Withdrawal (detox) or Medical Social Worker Meeting Motor Vehicle Accident Not Applicable Narcotics Anonymous Sodium Neighborhood Alternative Center National Alliance for the Mentally Ill Narcotic No Added Salt or Neonatal Abstinence Syndrome National Association of Social Workers No Complaints National Council on Alcoholism and Drug Addiction
NCCA NEG NEURO NGP or TPNGP NGRI NIAAA NIDA NIDDM NIH NIMH NKA NKDA NMS NOA NOC NOS NPI NPO NPPES NREPP NS NSG NSH NTP NTE NV O O2 O OB OBIC OBOT OBS OCC OCD OD O.D. ODD OINT OMI OOB OP OPG O/R OTC Ox4 Outpt Oz
National Commission for Certifying Agencies Negative Neurological Northgate Point (Turning Point Northgate Point) Not Guilty by Reason of Insanity National Institute of Alcoholism and Alcohol Abuse National Institute of Drug Abuse Non Insulin Dependent Diabetes Mellitus National Institute of Health National Institute of Mental Health No Known Allergies No Known Drug Allergies Neuroleptic Malignant Syndrome Notice Of Action Night Not Otherwise Specified National Provider Identifier Nothing by Mouth National Plan and Provider Enumeration System National Registry of Evidence-based Programs and Practices No Show Nursing Napa State Hospital Narcotic Treatment Program Not to Exceed Nausea & Vomiting Oxygen Oral Obstetrics Outpatient Buophrenorphine Induction Clinic Office-Based Opiate Treatment Services Organic Brain Syndrome Occasionally Obsessive Compulsive Disorder Overdose Ocular Dexter (Right Eye) Oppositional Defiant disorder Ointment Oceanview, Merced Heights and Ingleside Out of Bed Outpatient Office of Problem Gambling Own Recognizance Over the Counter Oriented times 4 Outpatient Ounce
P p p.c. p.r.n. P/C P= PADs PAP PC P.C. PCN PCP PCP/PMD PD PDD PDR PE PERRL Per PES PFU PG PhD Ø barb PHF PHI PHN PIN PM pm PMA PMR PN PO po POS POST OP PPD PREG PRE OP PREP PROB PROG PSW PsyD pt P/T PTSD
After After Meals As Needed Phone Call Pulse is Preventive Aggression Devices Papanicolaou Test Primary Care Penal Code Penicillin Phencyclidine Primary Care Provider Plan Development Pervasive Developmental Disorder Physician’s Desk Reference Psychiatric Exam Pupils Equal, Round, Reactive to Light By / Through Psychiatric Emergency Services Provider File Update Public Guardian Doctor of Philosophy Phenobarbital Psychiatric Health Facility Protected Health Information Public Health Nurse Provider Identification Number Program Manager Afternoon Psychomotor Agitation Psychomotor Retardation Psychiatric Nurse Probation Officer By Mouth Point of Service After Operation Purified Protein Derivative for Tuberculosis Test Pregnant Before Operation Preparation Problem Progress Psychiatric Social Worker or Protective Services Worker Doctor of Psychology Patient Part Time Post Traumatic Stress Disorder
P/U PURQC PVC’s Px Q q q2h QA qam qh QIC qid qs qt R R R&R R/O R= RAMS RBC RD REC’D RE REC REG REHAB REL REL Of INFO or ROI REM RESP REV RFP RFQ R/L RLE RLQ RN RES TX CNTR ROM ROS R or rt RTC RU# RUE RUQ Rx Rxn
Pick Up Program Utilization Review Quality Committee Premature Ventricular Contractions Physical Every Every 2 hours Quality Assurance Every Morning Every Hour Quality Improvement Coordinator/Committee Four Times a day Quantity Sufficient Quart Respiration Re-Assessment & Re-Authorization Plan Rule-Out Respirations Are Richmond Area Multi-Service Inc. Red Blood Count Right Deltoid Received Regarding Recommend Regular Rehabilitation Relationship Release of Information Rapid Eye Movement Respiratory Review Request for Proposals Request for Qualifications Right/Left Right Lower Extremity Right Lower Quadrant Registered Nurse Residential Treatment Center Range of Motion Review of Systems Right Return to Clinic Reporting Unit Number Right Upper Extremity Right Upper Quadrant Prescription Reaction
S S SA SACPA SAMHSA SCHIZ SCUT SDI SDMC SE SECFTC SED SLP S&R S/S S/A SBO SFGH SFMHP SFUSD SGOT SGPT S/I SIB sib sis SMAST SNF SOB SOC SOC Hx SOC PM SOC-QIC S/O S/P SPMD SPY SRS SSA SSI SSDI SSRI Staph STAT STD Strep SUBJ SUBQ
Without Substance Abuse Substance Abused Crime Prevention Act (Prop 36) Substance Abuse and Mental Health Services Administration Schizophrenia Schizophrenia, Chronic Undifferentiated Type State Disability Insurance Short-Doyle MediCal Side Effects South East Child & Family Therapy Center Severely Emotionally Disturb Supported Living Program Seclusion & Restraint Signs and Symptoms Suicide Attempt School Based Outpatient San Francisco General Hospital San Francisco Mental Health Plan San Francisco Unified School District Serum Glutamic-Oxaloacetic Transaminase Serum Glutamic-Pyruvic Transaminase Suicide Ideation Self Injurious Behavior(s) Sibling Sister Short Michigan Alcohol Screening Test Skilled Nursing Facility Shortness of Breath System of Care Social History System of Care Program Manager System of Care Quality Improvement Committee Significant Other Status Post Serious and Persistent Mental Disorder Special Programs for Youth Session Rating Scale Social Security Administration Supplemental Security Income Social Security Disability Insurance Selective Serotonin Reuptake Inhibitor Staphylococcus Immediately Sexually Transmitted Disease Streptococcus Subject Subcutaneously
SUD SVP SW Sx Sz T TAY TA TC T/C T/O T= or Temp Tab TAP TV TB TBI TBS Tbsp. TCA TCM TCN TCON TCPC TD TEDS TIA tid tinct. TIP TANF THC TPR TAR TRO TSH tsp. Tox Tx TRH TVS TYS U U/A UCI UCSF U.A. UCSFMC
Substance Use Disorder Sexually Violent Predator Social Worker Symptoms Seizures Transitional Age Youth Technical Assistance Therapeutic Community Telephone Call Telephone Order Temperature is Tablet Treatment Access Program Television Tuberculosis Traumatic Brain Injury Therapeutic Behavioral Services Tablespoon Tri-Cyclic Antidepressants Targeted Case Management Tetracycline Temporary Conservatorship Treatment Center Program Coordinator Tardive Dyskinesia Treatment Episode Data Set Transient Ischemic Attack Three Times A Day Tincture Treatment Improvement Protocol Temporary Assistance to Needy Families Tetrahydrocannabinol (active ingredient to Marijuana) Temperature, Pulse, Respirations Treatment Authorization Request Temporary Restraining Order Thyroid-Stimulating Hormone Teaspoon Toxicology Treatment Thyroid releasing hormone Therapeutic Visitation Services Transitional Youth Services Urinalysis Unique Client Identifier University of California San Francisco Unauthorized Absence University of California San Francisco Medical Center
UOS UDS ULQ UGI UM UMDAP UNG UNK UR URI URQ UTI Utox V VA VD VDRL V/H VM V/O V/S VOC REHAB Vol VPA VS VSS W W W&I WIC W/C w/o w/ W/D WD/WN WBC WK WNL Wt. X X Y YGC Y/O YR Z Zn
Unit of Service Urine Drug Screen Upper Left Quadrant Upper Gastrointestinal Series Utilization Management Uniform Method for Determining Ability to Pay Ointment Unknown Utilization Review Upper Respiratory Infection Upper Right Quadrant Urinary Tract Infection Urine Toxicology Screen Veterans Administration Venereal Decease Test for syphilis Visual Hallucinations Voice Mail/ Voice Message Verbal Order Visions South Vocational Rehabilitation Voluntary Valproic Acid/Valproate Vital Signs Vital Signs Stable White California Welfare and Institutions Code Women’s, Infants & Children Wheelchair Without With Withdrawal Well-Developed, Well-Nourished White Blood Cell Count Week Within Normal Limits Weight Multiplied by/times Youth Guidance Center Years Old Year Zinc
Symbols ≤ ≥ ↑ ↓ ♀ ♂ 1º 2º # % + 1:1 ” ‘ ? & @ = 5150 5250
Psychiatric/ Psychiatrist/Psychology Less Than or Equal To Greater Than or Equal To Increase Decrease Female Male Primary Due to; Secondary to Number Percent Plus, positive, yes Minus, negative, no One to one Inches Feet Unknown And At Equal WIC 72 hour hold for mental health evaluation WIC 14 day hold
Section 6: Appendix J American Psychiatric Association CPT Coding Resources for APA Members
CPT Coding Changes for 2013 Initial Psychiatric Evaluation (formerly 90801 or new patient E/M code) 90791, Psychiatric diagnostic evaluation (no medical services) 90792, Psychiatric diagnostic evaluation (with medical services) (New patient E/M codes may be used in lieu of 90792)
Psychotherapy (formerly 90804-90808, 90816-90821) For use in all settings; time is with patient and/or family) 90832, psychotherapy, 30 minutes 90834, psychotherapy, 45 minutes 90837, psychotherapy, 60 minutes
Evaluation Management (E/M) and Psychotherapy (formerly 90805-90809, 90817-90822) Appropriate E/M code (not selected on basis of time), and 90833, 30-minute psychotherapy add-on code Appropriate E/M code (not selected on basis of time), and 90836, 45-minute psychotherapy add-on code Appropriate E/M code (not selected on basis of time), and 90838, 60-minute psychotherapy add-on code
Medication Management (formerly 90862 or E/M code) Appropriate E/M code (99xxx series)
Interactive Psychotherapy (formerly 90802, 90810-90815, 90823-90829, 90857) For use with the psychiatric evaluation codes, the psychotherapy and psychotherapy add-on codes, and the group (non-family) psychotherapy code 90785, interactive psychotherapy
Crisis Psychotherapy (new) 90839, psychotherapy for crisis, first 60 minutes (Appropriate E/M code may be used in lieu of 90839) 90840, psychotherapy for crisis, each additional 30 minutes These changes take effect January 1, 2013. Questions – Go to http://www.psychiatry.org/practice, or call 800-343-4671 or send an email to
[email protected]. To purchase a copy of the 2013 CPT manual call the AMA at 800-621-8335 or go to https://catalog.ama-assn.org/Catalog/home.jsp . CPT® five-digit codes, descriptions, and other data only are copyright 2011 by the American Medical Association (AMA). All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT®. CPT® is a registered trademark of the American Medical Association (AMA).
108
American Psychiatric Association CPT Coding Resources for APA Members
Crosswalk of 2012 CPT Codes to 2013 CPT Codes The following table provides a crosswalk between the CPT coding options in 2012 to the CPT coding options that take effect on January 1, 2013. In addition to new numbers and revised or new descriptors, a new concept – add-on codes – has been introduced. This list includes only those codes that have been revised in some way and is not a full list of CPT codes describing psychiatric work. We encourage everyone to purchase the 2013 edition of the CPT manual from the AMA (see below) and to visit APA’s website for information on webinars and other educational opportunities.
2012 Code
2013 Code(s) Initial Psychiatric Evaluation 90791, psychiatric diagnostic evaluation (no medical services) 90792, psychiatric diagnostic evaluation with medical services (E/M new patient codes may be used in lieu of 90792) 90791 or 90792, with 90785 (interactive complexity add-on code)
90801, psychiatric diagnostic evaluation 90802, interactive psychiatric diagnostic evaluation
Outpatient Psychotherapy (Time is face-to-face with patient) 90804, outpatient psychotherapy 20-30 min. 90805, outpatient psychotherapy w/ E/M services 20-30 min. 90806, outpatient psychotherapy 45-50 min. 90807, outpatient psychotherapy w/ E/M services 45-50 min. 90808, outpatient psychotherapy 75-80 min. 90809, outpatient psychotherapy w/ E/M services 75-80 min.
(Time is with patient and/or family) 90832, psychotherapy, 30 min. Appropriate outpatient E/M code (not selected on basis of time), and 90833, 30-minute psychotherapy add-on code 90834, psychotherapy, 45 min. Appropriate outpatient E/M code (not selected on basis of time), and 90836, 45-minute psychotherapy add-on code 90837, psychotherapy, 60 min. Appropriate outpatient E/M code (not selected on basis of time), and 90838, 60-minute psychotherapy add-on code
Outpatient Interactive Psychotherapy (Time is face-to-face with patient) 90810, interactive psychotherapy, 20-30 min. 90811, interactive psychotherapy w/ E/M, 2030 min. 90812, interactive psychotherapy, 45-50 min. 90813, interactive psychotherapy w/ E/M, 4550 min. 90814, interactive psychotherapy, 75-80 min. 90815, interactive psychotherapy w/ E/M, 7580 min.
(Time is with patient and/or family) 90832 psychotherapy, 30 min., and 90785, interactive complexity add-on code Appropriate outpatient E/M code (not selected on basis of time), and 90833, 30-minute psychotherapy add-on code, and 90785, interactive complexity add-on code 90834, psychotherapy, 45 min. and 90785, interactive complexity add-on code Appropriate outpatient E/M code (not selected on basis of time), and 90836, 45-minute psychotherapy add-on code, and 90785, interactive complexity add-on code 90837, psychotherapy, 60 min., and 90785, interactive complexity add-on code Appropriate outpatient E/M code (not selected on basis of time), and 90838, 60-minute psychotherapy add-on code, and 90785, interactive complexity add-on code
CPT® five-digit codes, descriptions, and other data only are copyright 2011 by the American Medical Association (AMA). All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT®. CPT® is a registered trademark of the American Medical Association (AMA).
American Psychiatric Association CPT Coding Resources for APA Members
Crosswalk of 2012 CPT Codes to 2013 CPT Codes 2012 Code
2013 Code(s) Inpatient Psychotherapy
(Time is face-to-face with patient) (Time is with patient and/or family) 90816, inpatient psychotherapy, 20-30 min. 90832, psychotherapy, 30 min. 90817, inpatient psychotherapy, 20-30 min. w/ Appropriate inpatient E/M code (not selected on basis of time), and E/M 90833, 30-minute psychotherapy add-on code 90818, inpatient psychotherapy, 45-50 min. 90834, psychotherapy, 45 min. Appropriate inpatient E/M code (not selected on basis of time), and 90819, 45-50 min. w/ E/M 90836, 45-minute psychotherapy add-on code 90821, inpatient psychotherapy, 75-80 min. 90837, psychotherapy, 60 min. Appropriate inpatient E/M code (not selected on basis of time), and 90822,75-80 min. w/ E/M 90838, 60-minute psychotherapy add-on code
Interactive Inpatient Psychotherapy (Time is face-to-face with patient) 90823, interactive inpatient psychotherapy, 2030 min. 90824, interactive inpatient psychotherapy, 2030 min. w/ E/M 90826, interactive inpatient psychotherapy, 4550 min. 90827, interactive inpatient psychotherapy, 4550 min. w/ E/M 90828, interactive inpatient psychotherapy, 7580 min. 90829, interactive inpatient psychotherapy, 7580 min. w/ E/M
(Time is with patient and/or family) 90832, psychotherapy, 30 min. 90785, interactive complexity add-on code Appropriate inpatient E/M code (not selected on basis of time), and 90833, 30-minute psychotherapy add-on code, and 90785, interactive complexity add-on code 90834, psychotherapy, 45 min. 90785, interactive complexity add-on code Appropriate inpatient E/M code (not selected on basis of time), and 90836, 45-minute psychotherapy add-on code, and 90785, interactive complexity add-on code 90837, psychotherapy, 60 min. 90785, interactive complexity add-on code Appropriate inpatient E/M code (not selected on basis of time), and 90838, 60-minute psychotherapy add-on code, and 90785, interactive complexity add-on code
Other Psychotherapy Codes 90857, Interactive group psychotherapy No existing code No existing code
90853, group psychotherapy (other than of multi-family), and 90785, interactive complexity add-on code 90839, psychotherapy for crisis, first 60 min. 90840, crisis code add on for each additional 30 min.
Other Psychiatric Services or Procedures 90862, pharmacologic management
Appropriate E/M code
Questions – Go to http://www.psychiatry.org/practice , or call 800-343-4671 or send an email to
[email protected]. To purchase a copy of the 2013 CPT manual call the AMA at 800-621-8335 or go to https://catalog.amaassn.org/Catalog/home.jsp .
CPT® five-digit codes, descriptions, and other data only are copyright 2011 by the American Medical Association (AMA). All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT®. CPT® is a registered trademark of the American Medical Association (AMA).
Interactive Complexity What is Interactive Complexity? A new concept in 2013, interactive complexity refers to 4 specific communication factors during a visit that complicate delivery of the primary psychiatric procedure. This is now reported with a CPT add-‐on code – 90785. Add-‐on codes may be reported in conjunction with specified primary procedure codes. Add-‐on codes can never be billed independently. The add-‐on code, 90785, replaces several old codes which will be deleted as of January 1, 2013. These include interactive diagnostic examination (90802), and all the interactive psychotherapy codes (90810 – 90815) and interactive group psychotherapy (90857). Interactive complexity (90785) reports the increased work intensity of the psychotherapy service and does not change the face-‐to-‐face time for psychotherapy services. This code cannot be used in conjunction with psychotherapy for crisis (90839 & 90840), E/M (Medication Support) only codes (99XXX codes), nor family psychotherapy codes (90846, 90847, nor 90849). The typical patient that may required the use of interactive complexity is cient’s that have other individual legally responsible for their care, such as minors or adults with guardians, or a client that requests other to be involved in their care during a visit (i.e. adults accompanied by one or more participating family members, interpreter or language translator) or a client who requires the involvement of other third party participants (i.e., child welfare agency, parole, probation officers or school teachers/counselors). In addition, one of the following communication factors must be present during the visit: a. There must be a need to manage maladaptive communication among participants that complicates delivery of care, such as high anxiety, high reactivity, repeated questions or disagreements). b. Caregiver emotions or behaviors interfere with implementation of the treatment plan. c. There is evidence/disclosure of a sentinel event and mandated report to a third party such as abuse or neglect with initiation of discussion of the sentinel event or report with the patient and other participants. This sentinel event is usually reported to a state or local agency for investigation. d. There is use of play equipment, physical devices, interpreter or translator to overcome barriers to diagnostic or therapeutic interaction with the patient who is not fluent in the same language or who has not developed or has lost expressive or receptive language skills to use to understand typical language. Reference: CPT Code book, American Academy of Child & Adolescent Psychiatry.
C i t y a n d C o u n t y o f S a n F r a n c i s c o D e p a r t m e n t o f P u b l i c H e a l t h DPH COMPLIANCE OFFICE 1380 Howard Street. 4th Floor San Francisco, CA 94103 Edwin M. Lee Mayor
1001 Potrero Ave. Bldg 10, Ward 15 San Francisco, CA 94110 Memorandum
December 3, 2012 FOR IMMEDIATE RELEASE RE: Psychotherapy CPT® Codes Changes Effective Jan. 1, 2013
Dear Colleagues: Beginning Jan. 1, 2013, all mental health providers must use new CPT® code numbers for psychiatric diagnostic evaluation and psychotherapy when billing third-party payers, including Medicare, Medi-Cal, and private health insurance carriers. Enclosed please find the Psychotherapy CPT® handout, published by the American Psychological Association (October, 2012), which contains a list of new psychotherapy code numbers for all non-prescribing mental health providers and a crosswalk that compares the 2012 codes to the new codes that take effect on Jan. 1, 2013. Of note, while the diagnostic and therapeutic services have new code numbers, the fundamental services underlying the codes will not change. Please review this letter and attached documents carefully. Should you have any questions regarding coding, billing, and documentation of services, please consult with your clinical supervisor and/or program director.
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Psychiatric Diagnostic Evaluation A distinction has been made between diagnostic evaluations with medical services and evaluations without medical services. Two new codes have been introduced which distinguish between an initial evaluation with medical services by a physician (90792) and an initial evaluation provided by a non-physician (90791). 2012 (Old) Ø 90801
2013 (New) 90791, Psychiatric diagnostic evaluation
Ø 90802
90791 plus 90785, Psychiatric diagnostic evaluation with interactive complexity
Of note: Ø Interactive services are captured using an add-on code (90785) Ø These codes can be used in any setting Ø These codes can be used more than once in those instances where the patient other informants are included in the evaluation Ø These codes can be used for reassessments
Basic Psychotherapy Code Changes Descriptions of the three new psychotherapy codes in the 2013 CPT manual are associated with specific times rather than the current time ranges that apply to these services (noted below in parentheses): •
New Code 90832: Psychotherapy, 30 minutes with patient and/or family member (not 20-30 minutes)
•
New Code 90834: Psychotherapy, 45 minutes with patient and/or family member (not 45-50 minutes)
•
New Code 90837: Psychotherapy, 60 minutes with patient and/or family member (not 75-80 minutes)
According to the 2013 CPT manual, psychotherapy times are for face-to-face services with the patient and/or family member, with the patient present for some or all of the service. Although the time for each code is specific, the manual allows for some flexibility. When reporting a psychotherapy service, the provider may choose the code closest to the actual time of the session. The examples provided in the manual are 16-37 minutes for code 90832, 38-52 minutes for 90834, and 53 minutes or more for 90837.
Psychotherapy Overview--A couple of additional highlights related to psychotherapy codes for 2013 include: • Outpatient and inpatient psychotherapy codes will be replaced by a single set of codes to be used for both settings •
Psychotherapy codes are no longer site specific. The new changes allows all codes to be reported in all settings without regard to site
•
Psychotherapy times includes face-to-face time spent with the patient and/or family member
Page 2 of 5 | R M
•
Time is chosen according to the **CPT time rule
•
Interactive psychotherapy is reported using the appropriate psychotherapy code along with the interactive complexity add-on code
•
The code numbers and descriptions for psychoanalysis, family psychotherapy (with and without the patient), multifamily group psychotherapy and group psychotherapy will not change in 2013.
Add-on Codes There will be new “add-on” codes for specific services that can be provided only in combination with other diagnostic evaluation, psychotherapy and group psychotherapy services. Add-on codes identify an additional part of the treatment above and beyond the principal service. Both the principal service code and add-on code should be listed on the billing form. The codes for interactive psychotherapy are being eliminated and replaced with an add-on code to capture “interactive complexity.” Interactive Complexity, new add-on code 90785, refers to factors that complicate the delivery of a mental health procedure. “Interactive” in previous codes was limited in use to times when physical aids, translators, interpreters, and play therapy was used. “Interactive Complexity" extends the use to include other complicating factors such as: •
Arguing or emotional family members in a session that interfere with providing the service
•
Third party involvement with the patient, including parents, guardians, courts, schools, and others such as family members or interpreters to be involved during the visit, or
•
Need for mandatory reporting of a sentinel event
Code 90785 may be reported with codes for diagnostic evaluation, psychotherapy and group psychotherapy. At least one of several circumstances identified in the CPT manual that complicate the delivery of care must pertain in order for providers to bill the interactive complexity code as an add-on to the principal psychiatric procedure. PLEASE NOTE: 90785 (add-on code) is never reported alone. Example: You see a monolingual Spanish-speaking patient for 30 minutes for outpatient psychotherapy-- you would code 90832 plus 90785: Psychotherapy, 30 minutes with interactive complexity add-on.
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Pharmacologic Management Of particular interest to prescribing psychologists, a new add-on code 90863 will be used for pharmacologic management, including prescription and review of medication, when performed with psychotherapy services. A psychologist providing a psychotherapy service with medication management should report the 90863 add-on code along with the applicable new psychotherapy code identified above.
New Crisis Codes There is a new principal code for a crisis psychotherapy session requiring urgent assessment and history of the crisis state, mental status exam and disposition. A new add-on code applies to crisis psychotherapy sessions lasting longer than 60 minutes. In order for the new crisis codes to apply, the presenting problem must typically be life threatening or complex and require immediate attention to a patient in high distress. Code 90839** will be billed for the first 60 minutes of psychotherapy for a patient in crisis, and add-on code 90840 will be billed for each additional 30 minutes of psychotherapy for crisis. Other things to keep in mind when providing crisis service: Ø Time does not have to be continuous Ø Provider must devote full attention to patient and cannot provide services to other patients during time period Ø 90839 (60 min) used for first 30-74 minutes Ø Reported only once per day Ø 90840 (each additional 30 min) report for up to 30 minutes beyond 74 minutes. Ø Example: 120 min of crisis therapy reported: • •
90839 x 1 90840 x 2
Ø Less than 30 minutes reported with codes 90832 or 90833 (psychotherapy 30 min) Ø Remember, presenting problem typically life-threatening or complex and requires immediate attention to a patient in high distress Ø Codes include: • • •
Urgent assessment and history of crisis state Mental status exam Disposition
Ø Treatment includes: • •
Psychotherapy Mobilization of resources to diffuse crisis and restore safety
Page 4 of 5 | R M
•
Implementation of psychotherapeutic interventions to minimize potential for psychological trauma
Ø Codes for crisis services cannot be reported in combination with: • • •
90791, 90792 (diagnostic services) 90832-90838 (psychotherapy) 90785 (interactive complexity)
** CPT Time Rule Ø “A unit of time is attained when the mid-point is passed” Ø “When codes are ranked in sequential typical times and the actual time is between two typical times, the code with the typical time closest to the actual time is used.” Ø As an example, codes of 30, 45, and 60 minutes are billed at 16-37 mins, 38-52 mins, and 53-67 mins. Ø For Crisis Services: 90839, Psychotherapy for crisis, first 60 minutes (CPT Rule applies: 30-74 minutes) 90840, Psychotherapy for crisis each additional 30 minutes Sources: American Psychological Association Practice Organization (www.apapracticecentral.org). ® Current Procedural Terminology (CPT ) copyright 2011 American Medical Association. All Rights Reserved. Musher, J., Falcone, A., and Swann, D (Nov. 2012). CPT Code Changes for 2013: Impact on Behavioral Health. The National Council For Community Behavioral Health Care. Ronald Burd, MD (November 9, 2012): CPT Coding Changes for 2013 Webinar, American Psychiatric Association.
Attachment: 1. APA 2013 Psychotherapy CPT® Codes for Psychologists/Mental Health Providers 2. APA Crosswalk of 2012 Psychotherapy CPT® Codes to 2013 Codes 3. CBHS Crosswalk: 2012 to 2013 CPT® Code Sets for Non-Physicians
Page 5 of 5 | R M
Putting Your Practice Assessment to Work
2013 Psychotherapy CPT® Codes for Psychologists Effective January 1, 2013
Diagnostic interview procedures 90791
Psychiatric diagnostic evaluation Psychotherapy
90832
Psychotherapy, 30 minutes with patient and/or family member
90834
Psychotherapy, 45 minutes with patient and/or family member
90837
Psychotherapy, 60 minutes with patient and/or family member
90845*
Psychoanalysis
90846*
Family psychotherapy without the patient present
90847*
Family psychotherapy, conjoint psychotherapy with the patient present
90849*
Multiple-family group psychotherapy
90853*
Group psychotherapy (other than of a multiple-family group)
90785
Interactive complexity add-on code Add-on code to be used in conjunction with codes for primary service: psychiatric diagnostic evaluation (90791); psychotherapy (90832, 90834, 90837); and group psychotherapy (90853) Psychotherapy for crisis
90839
Psychotherapy for crisis, first 60 minutes
90840
90863
Add-on for each additional 30 minutes of psychotherapy for crisis, used in conjunction with code 90839 Pharmacologic management add-on code Pharmacologic management, including prescription and review of medication, when performed with psychotherapy services; used only as add-on to primary psychotherapy code (90832, 90834, 90837)
* The codes shaded in orange are the same for 2012 and 2013
Current Procedural Terminology®(CPT) copyright 2011 American Medical Association. All Rights Reserved. The CPT manual is available for purchase from the American Medical Association online or by calling toll-free, (800) 621-8335.
For complete information on the 2013 psychotherapy codes, visit www.apapracticecentral.org/codes. For additional questions, email us at
[email protected].
American Psychological Association Practice Organization Practitioner Helpline: 800-374-2723 TDD/TTY: 202-336-6123
Putting Your Practice Assessment to Work
Crosswalk of 2012 Psychotherapy CPT® Codes to 2013 Codes Effective January 1, 2013
2012 Code
2013 Code(s)
Diagnostic interview procedures 90801, Psychiatric diagnostic interview 90791, Psychiatric diagnostic evaluation examination Psychotherapy 90804, outpatient psychotherapy 20-30 min 90832, Psychotherapy, 30 minutes with patient 90816, inpatient psychotherapy 20-30 min and/or family member 90806, outpatient psychotherapy 45-50 min 90834, Psychotherapy, 45 minutes with patient 90818, inpatient psychotherapy 45-50 min and/or family member 90808, outpatient psychotherapy 75-80 min 90837, Psychotherapy, 60 minutes with patient 90821, inpatient psychotherapy 75-80 min and/or family member 90845,* Psychoanalysis
90845, Psychoanalysis
90846,* Family psychotherapy without the patient present 90847,* Family psychotherapy, conjoint psychotherapy with the patient present
90846, Family psychotherapy without the patient present 90847, Family psychotherapy, conjoint psychotherapy with the patient present
90849,* Multiple-family group psychotherapy
90849, Multiple-family group psychotherapy
90853,* Group psychotherapy (other than of a 90853, Group psychotherapy (other than of a multiple-family group) multiple-family group) Codes for interactive services 90802, Interactive psychiatric diagnostic 90791 plus interactive add-on code (90785) evaluation All current interactive psychotherapy services 90785, Add-on code to be used in conjunction (90810 – 90815, 90823 – 90829) with appropriate psychotherapy code based on length of the session 90857, Interactive group psychotherapy 90853 plus interactive add-on code (90785) Pharmacologic management add-on code 90862, Pharmacologic management, including 90863, Pharmacologic management, including prescription, use and review of medication with prescription and review of medication, when no more than minimal medical psychotherapy performed with psychotherapy services; used only as add-on to principal psychotherapy code (90832, 90834, 90837) * The codes shaded in orange are the same for 2012 and 2013 Current Procedural Terminology®(CPT) copyright 2011 American Medical Association. All Rights Reserved. The CPT manual is available for purchase from the American Medical Association online or by calling toll-free, (800) 621-8335.
For complete information on the 2013 psychotherapy codes, visit www.apapracticecentral.org/codes. For additional questions, email us at
[email protected]. American Psychological Association Practice Organization Practitioner Helpline: 800-374-2723 TDD/TTY: 202-336-6123
C i t y a n d C o u n t y o f S a n F r a n c i s c o D e p a r t m e n t o f P u b l i c H e a l t h Ravi Mehta, Psy.D. DPH COMPLIANCE OFFICE 1380 Howard Street San Francisco, CA 94103
Crosswalk: 2012 to 2013 CPT Code Sets for NON-‐PHYSICIANS Effective January 1, 2013 2012 Code (Deleted)
90801: Psychiatric diagnostic evaluation 90802: Interactive psychiatric diagnostic evaluation
2013 Code Report w/Code for Interactive Complexity (90785) (NEW, starting Jan 1. 2013) DIAGNOSTIC PROCEDURES 90791: Psychiatric diagnostic evaluation (no medical services)
+
When appropriate
90791
+
90785
PSYCHOTHERAPY 90804: Outpatient psychotherapy, 20-‐30 min. 90806: Outpatient psychotherapy, 45-‐50 min. 90808: Outpatient psychotherapy, 75-‐80 min.
90832: psychotherapy, 30 mins + When appropriate 90834: psychotherapy, 45 mins + When appropriate 90837: psychotherapy, 60 mins + When appropriate INTERACTIVE PSYCHOTHERAPY
90810: Interactive psychotherapy, 20-‐30 min. 90812: interactive psychotherapy, 45-‐50 min. 90814: interactive psychotherapy, 75-‐80 min.
90832: psychotherapy, 30 mins + 90785 90834: psychotherapy, 45 mins + 90785 90837: psychotherapy, 60 mins + 90785 OTHER
90857: Interactive Group Psychotherapy
90853: Group Psychotherapy (other than + multiple-‐family group) 90839: Crisis psychotherapy, first 60 mins 90840: Crisis psychotherapy, each additional 30 mins.
NEW
90785
NO
Current Procedural Terminology®(CPT) copyright 2011 American Medical Association. All Rights Reserved. The CPT manual is available for purchase from the American Medical Association online or by calling toll-free, (800) 621-8335.
RM 12/6/12
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