Medi-Cal Coding and Documentation Requirements

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Starring:

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Why document services?

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4 Reasons to Document

nSupports quality healthcare

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nBasis of billing claims and getting paid

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Sound charting allows us to keep going as an agency because it is what allows us to generate and = protect revenue for client services= .

STAFF

REFERENCE MATERIALS

TRAINING

FACILITIES

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STAFF

<= span class=3DBB style=3D'position:absolute;left:-4.43%;top:.49em'>nLicen= sed Mental Health Professional (LMHP)

nLPHA=

nRN, = LVN, PT

nOT&#= 13;

nMHRS=

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STAFF: LPHA

nLicense Practitioner of the Healing Arts

nLicensed (and registered/waivered)

nPsychologists

nClinical Social Workers

nMarriage and Family Therapists

nPsychiatrists

nRNP and RN/MSN with Experience

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STAFF: MHRS

nMental Health Resource Specialist

nAssociate with 6 years experience

nBachelors with 4 years experience

nMasters with 2 years experience

n

nCredentialing is delegated duty of program. =

nExperience must be in mental, rehabilitative and health care setting.

nNO EXCEPTION!

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Medi-Cal Specialty Mental Health = Services

<= span style=3D'font-size:106%'>nTypes of Services=

<= span style=3D'font-size:106%;visibility:hidden'>n&#= 13;

<= span style=3D'font-size:106%'>nMedi-Cal Codes= 3;

<= span style=3D'font-size:106%;visibility:hidden'>n&#= 13;

<= span style=3D'font-size:106%'>nDocumentation Sta= ndards

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Type= s of Community Services

nPlanned Services<= /b>

nCase Management/Brokerage

nMenta= l Health Services

nDay T= reatment Services

nMedic= ation Support Services

nUnplanned Services

nCrisis Intervention

n

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Mental = Health Services

nMental Health Services are interventions designed to provide the maximum reduction of mental disability and restoration or maintenance of functioni= ng consistent with the requirements for learning, development, independent li= ving and enhanced self-sufficiency. Services shall be directed toward achieving= the Individual’s goals/desired results/personal milestones.

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MHS STA= FF

nStaff required: Licensed Mental Health Professionals (LMHP)

nOthers may provide services

nscope of competency

nappropriate supervision

nco-signature of LMHP

n (within their scope of pract= ice and competency)

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Types of Mental Health Services

1.Assessment

2.Collateral

3.Plan Development

4.Re= habilitation (Individ= ual/Group)

5.Th= erapy (Individ= ual/Group/Family)

6.

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MHS: Assessment

nAssessment means= a service activity which may include a clinical analysis of the = history and current status of a beneficiary’s mental, emotional= , or behavioral disorder, relevant cultural = issues and history. Assessment may include diagnosis and the use of test= ing = procedures. (BROAD DEFINITION)

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Assessment

<= span class=3DBB style=3D'position:absolute;left:-4.31%;top:.49em'>nLicen= sed Mental Health Professionals

<= span style=3D'visibility:hidden'>n

<= span class=3DBB style=3D'position:absolute;left:-4.43%;top:.49em'>nConsi= stent with Scope of Practice

n Legal

<= span class=3DBB style=3D'position:absolute;left:-4.2%;top:.49em'>nConsis= tent with Scope of Competence

n Ethical

nAppro= priate consultation or supervision

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Assessment STAFF

nLPHA

nMental Status Exam (MSE)

nEstablishing Diagnosis

n MFTI/ASW requires LPHA Co-sign

nNon-LPHA

nMini-MSE (MMSE)

nRecommend: policy, protocol and scripted interview

nCollect Information

nWrite ‘diagnosis established by’ LPHA name.

nPut supporting documentation in chart.

n

n

------=_NextPart_01C50546.247627E0 Content-Location: file:///C:/EC2C4CD1/1_files/slide0006.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Medi-Cal Coding and Documentation Requirements

MHS: Collateral

nCollateral means a service activity to a <= /span>= significant support person in a = = beneficiary’s life with the intent of improving or maintain the mental health status of the beneficiary. The beneficiary may or may not be present for this service = activity.

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UwDn18l5ziLFs5P1zOf63pfEgs7ylrv8ZQAzugMEroGBzYzjNE+axyFzsKXfnGnvbZrTYAX1h/ss YlJfedBCKLQgDu3lRINZzI0uswjO3C01n4DNtfbxrTGdgyzumteXpW+wAz3sFBsa1cqO8Yxr4Ojo joa6kZa2ZKvtZkyXctvclrCwsUxoFSM71YseMI2dDe1167qbwba+tEjpXW9eC0Hf5Fb0BmTc7Eev O9Z0nfWaqd1ga0sY4QnvOC2WvepWpxvSCbb4tEPmcY57fOUsB2co99rymMvc5cLE4sxvjnOQqDzn PO95ZnBrc58LfejOAPofiY70oe886Uxf+dKbDnVuPz3quwgEADs= ------=_NextPart_01C50546.247627E0 Content-Location: file:///C:/EC2C4CD1/1_files/slide0007.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Medi-Cal Coding and Documentation Requirements

MHS: Th= erapy

nTherapy means a service activity which is a = = therapeutic intervention that focuses primarily on symptom reduction as a means to improve functional impairments.
n

n

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Therapy STAFF

nLicense Practitioner of the Healing Arts

nLicensed/registered

n(Co-signature may be required for MFTI/ASW) =

n

nScope of Practice and Competency

n

nAppropriate Supervision and Consultation

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MHS: Rehabilitation

nRehabilitation means a service activity which includes assistance in improving, maintaining, or restoring a beneficiary’s or group of beneficiaries functional = skills, daily living skills, social and leisure skills,= grooming and personal hygiene skills, meal preparation skills<= /b>, and support resources; and/or medication education.
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MHS: Pl= an Development

nPlan Development= means a service activity which consists of development of client plans, approval of beneficiary plans and/or monitoring of a beneficiary’s progress.

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Treatment Plan STAFF

nStaff may contri= bute to the plan based upon their scope of practice and competency.
<= span class=3DBB style=3D'position:absolute;left:-4.43%;top:.49em'>nCompl= eted by LMHP

<= span class=3DBB style=3D'position:absolute;left:-4.43%;top:.49em'>nCo-Si= gnature of LPHA
<= span class=3DBB style=3D'position:absolute;left:-4.43%;top:.49em'>nIf medication, MD/RNP required

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Mental = Health Services

nBilling Unit

a)Men= tal Health Services billing unit is the time of the person delivering the service in minutes of= time.

b)The following requirements apply for claiming of services based on minutes of time: <= /span>

n

n <= /span>

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Mental = Health Services

1)The exact number of minutes used by persons providing a reimbursable service shall be reported and billed.

n=

2)Group service to or on behalf of more than one beneficiary at the same time. The facilitator’s time must be pro-rated to each beneficiary. <= /span>

n=

<= span style=3D'font-size:86%'>n<= span style=3D'font-size:86%'>Length of Service

<= span style=3D'font-size:86%'>n<= span style=3D'font-size:86%'>Number of Staff

<= span style=3D'font-size:86%'>n<= span style=3D'font-size:86%'>Number of participants

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Mental = Health Services

3)The= time required for documentation and travel is reimbursable when the documentation of travel i= s a component of reimbursable service activity. = ;

n

4)Plan development for Mental Health services is reimbursable. The unit of time may be billed regardless of whether there is face-to-face tim= e or phone contact with the beneficiary.<= /span>

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Mental = Health Services

nContact and Site Requirements
nMental Health Services may = be either face-to-face or by telephone with the = beneficiary or significant support persons and may be provided anywher= e in the community.

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Mental = Health Services

nLockouts
nMental Health Services are = not reimbursable when provided by Day Rehabilitation or Day Treatment staff during the same time period that Day Day Treatm= ent are provided. Children services have additional = limitations.

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Medica= tion Support Services

n“Medication Support Services” means those services which prescr= ibe, administer, dispense and monitor psychiatric medications or biologicals which are necessary to alleviate the symptoms of mental illness.

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Medica= tion Support Services

nContact and Site Requirements
n Medication Support Services may be either = face-to-face or by telephone with the beneficiary or significant support persons and may be provided anywhere in the = community.
n

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Medica= tion Support Services

nBilling Unit

1.Medication Support Services billing bills the time of the person delivering the service in minutes of time.

2.The following requirements apply for claiming of services based on minutes of time:

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Medica= tion Support Services

nBilling Unit

a)The exact number of minutes used by persons providing a reimbursable service shall be <= /span>reported and billed.

b)Group service to and or on behalf of more than one beneficiary at the same time, the person’= ;s time must be pro-rated to each beneficiary.=

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Medica= tion Support Services

nBilling Unit
<= span style=3D'font-size:88%'>nLength of Service

<= span style=3D'font-size:88%'>nNumber of Staf= f

<= span style=3D'font-size:88%'>nNumber of Beneficiaries

c)The time required for documentation and travel is reimbursable when the documentation of travel i= s a component of the reimbursable service activity.=

d)Plan development for Mental Health Services is reimbursable. Units of time may be billed regar= dless whether there is face-to-face time or phone con= tact with the beneficiar= y.

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Medica= tion Support Services

nLockouts
nThe maximum amount claimable for Medication Support Services in a 24-hour period is 4 hours.

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Targeted Case = Management/Brokerage

n“Targeted Ca= se Management” means servic= es that assist a beneficiary to access needed = <= span style=3D'font-size:75%'>medical, educational, social, prevocational, vocational, rehabilitative or other community <= /b>= services. Service activities may include, but are not limited to:

ØCommunication

ØCoordination

ØReferral

ØMonitoring service delivery to ensure beneficia= ry access to service and= the service delivery system

ØMonitoring of the beneficiary’s progress and

ØPlan development

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Targeted Case Management

nContact and Site Requirements
nTargeted Case Management ma= y be either face-to-face or by telephone with the beneficiary or significant support person and may be provided anywher= e in the community.

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Targeted Case Management

nBilling Unit
nTargeted Case Management billing unit is the time of the person delivering the service in minutes of time.
n

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Targeted Case Management

nBilling Unit

nThe exact number of minutes used by persons providing a reimbursable service shall be reported and billed.

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Targeted Case Management

nBilling Unit

nGroup service can be on behalf of more than one beneficiary at the same time. The person’s time must be pro-rated to each beneficiary

nLength of service

nNumber of Staff

nNumber of beneficiaries

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Targeted Case Management

nBilling Unit
nThe time required for documentation and travel is reimbursable when the documentation of travel time is a comp= onent of a reimbursable activity.
n

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Targeted Case Management

nBilling Unit
nPlan development for Mental Health Service is reimbursable. Units of time may be billed regardless of whether there is face-to-face time or phone contact with the beneficiary.
n

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Targeted Case Management

nLockouts

a)Targeted Ca= se Management Services are not reimbursable on days when the following servic= es are reimbursed, except for day of admission or for placement services as provided in sub-section (b):

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Targeted Case Management

nLockouts
nPsychiatric inpatient Hospital Services

1)Psychiatric Health Facility Services

2)Psychiatric Nursing Facility Services <= /span>

n

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Targeted Case Management

nLockouts

<= span style=3D'position:absolute;top:0%;left:8.27%;width:91.95%;height:100.0%'><= span style=3D'font-size:81%;font-weight:bold'>b)Targeted Case Management Services solely for the purpose of coordinating placement of the beneficiary on discharge from the psychiatric inpatient hospital, psychiatric health facility, or psychiatric nursing facility may be provided during the 30-calendar days immediately p= rior to the day of discharge, for a maximum of three non-consecutive periods of 30-calendar days or less per continuous stay in the facility.

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Targeted Case Management

nStaffing
nTargeted Case Management services may be provided by any person determined by the MHP to be qualified to provide the service, consistent with California law.

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Targeted Case Management

nWhen should this code be used:
nActivities provid= ed by program staff to access = needed services nWhich do not fit the definition for Mental Health Services.

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Crisis Intervention

n“Crisis Intervention” means a service lasting less than 24-hours to or on behalf of a beneficiary for a condition which requires a more timely response than a regularly scheduled visit. Service activities = may include, but are not limited to: = assessment, collateral, and therapy.

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Crisis Intervention

nCrisis Intervention is distinguished from = crisis stabilization by being delivered by providers who are not elig= ible to deliver crisis stabilization, or who are eligible, but <= /span>= deliver the service at a site other than a provider site that has been certified by the department or a Mental Health Plan to provide crisis stabilization.

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Crisis Intervention

nContact and Site Requirements
nCrisis Intervention may eit= her be face-to-face or by telephone with the beneficiary or significant support persons and may be provided anywhere in the community.

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