1	FOCUS focus focus….that bagel was good….I will eat wheat….focus…focus…oh I gotta call him….FOCUS….I’m not sure about that….oh, I gotta do that training on monday…focus..donuts…charting documentation.
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3	GOAL/ OBJECTIVES GOAL: 80% of participants write a narrative progress note consistent with documentation guidelines. Objectives: Deliver basic documentation guidelines to 100% of participants. 100% of participants do skill building training.
4	"“OOOOH" “OOOOH! Charting is such a chore!! I don’t have enough time as it is!!!”
5	"Alameda Behavioral Health Plan /..." Alameda Behavioral Health Plan / ACBHCS and it’s network of providers and contract organizations provide care to many beneficiaries each day.
6	Our common FOCUS is assisting beneficiaries meet their goals…
7	Sound charting allows us to keep going as an agency because it is what allows us to generate and protect revenue for client services.
8	4 Reasons to Document Supports quality healthcare Support continuity of care & coordination Basis of billing claims Protection against audits & malpractice
9	Medi-Cal Specialty Mental Health Services A) Types and Description of Services B) Billing Units C) Documentation Standards
10	A) Types of Services Planned Services 1.Day Treatment Services 2.Mental Health Services 3.Medication Support Services 4.Case Management Unplanned Services 5.Crisis Intervention
11	1. Day Treatment Intensive or Rehabilitation Option
12	2.Mental Health Services Mental Health Services are interventions designed to provide the maximum reduction of mental disability and restoration or maintenance of functioning consistent with the requirements for learning, development, independent living and enhanced self-sufficiency. Services shall be directed toward achieving the Individual’s goals/desired results/personal milestones.
13	Types of Mental Health Services Assessment Collateral Plan Development Rehabilitation (Individual/Group) Therapy (Individual/Group/Family)
14	MHS: Assessment Assessment 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 testing procedures.
15	MHS: Collateral Collateral means a service activity to a 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.
16	MHS: Therapy Therapy means a service activity which is a therapeutic intervention that focuses primarily on symptom reduction as a means to improve functional impairments.
17	MHS: Plan Development 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.
18	MHS: Rehabilitation Rehabilitation 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, and support resources; and/or medication education. (Individual or Group)
19	3.Medication Support Services “Medication Support Services” means those services which prescribe, administer, dispense and monitor psychiatric medications or biologicals which are necessary to alleviate the symptoms of mental illness.
20	Medication Support Services The services may include evaluation of the need for medication, 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 beneficiary.
21	Medication Support Services Billing Unit Length of Service Number of Staff Number of Beneficiaries The time required for documentation and travel is reimbursable when the documentation of travel is a component of the reimbursable service activity. Plan development for Mental Health Services is reimbursable. Units of time may be billed regardless whether there is face-to-face time or phone contact with the beneficiary.
22	4. Case Management (brokerage) “Targeted Case Management” means services that assist a beneficiary to access needed medical, educational, social, prevocational, vocational, rehabilitative or other community services. Service activities may include, but are not limited to: Communication Coordination Referral Monitoring service delivery to ensure beneficiary access to service and the service delivery system Monitoring of the beneficiary’s progress and Plan development
23	Case Management Billing Unit The time required for documentation and travel is reimbursable when the documentation of travel time is a component of a reimbursable activity.
24	Case Management Lockouts 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 sub-section (b):
25	Case Management Lockouts Psychiatric inpatient Hospital Services Psychiatric Health Facility Services Psychiatric Nursing Facility Services
26	5. Crisis Intervention “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.
27	Crisis Intervention Crisis Intervention is distinguished from crisis stabilization by being delivered by providers who are not eligible to deliver crisis stabilization, or who are eligible, but 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.
28	Crisis Intervention Billing Unit The time required for documentation and travel is reimbursable when the documentation of travel time is a component of a reimbursable activity.
29	Crisis Intervention Billing Unit Plan 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.
30	Crisis Intervention Staffing Crisis Intervention Services may be provided by any person determined by the MHP to be qualified to provide the service consistent with State law.
31	Crisis Intervention When the code should be used: A quick response to an unplanned event that has resulted in the individual's need for immediate service. Crisis intervention is typically an appropriate code to use when providing either an unplanned service contact, or when a scheduled service contact takes longer than it was scheduled.
32	Crisis Intervention Lockouts Crisis Intervention is not reimbursable on days when Crisis Residential Treatment Services, Psychiatric Nursing Facility Services, or Psychiatric Inpatient Hospital Services are reimbursed, except for the day of admission to those services. The maximum amount claimable for Crisis Intervention in a 24-hour day is eight (8) hours.
33	B) Service Billing Unit Billing Unit Mental Health Services billing unit is the time of the person delivering the service in minutes of time. The following requirements apply for claiming of services based on minutes of time:
34	Service Billing Unit The exact number of minutes used by persons providing a reimbursable service shall be reported and billed. 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. Length of Service Number of Staff Number of participants
35	Service Billing Unit The time required for documentation and travel is reimbursable when the documentation of travel is a component of reimbursable service activity. Plan development for Mental Health services is reimbursable. The unit of time may be billed regardless of whether there is face-to-face time or phone contact with the beneficiary.
36	Service Billing Unit Contact and Site Requirements Mental Health Services are expected to be face-to-face, but may be by telephone with the beneficiary or significant support persons.
37	C) Documentation Standards Conducting the Assessment Interview Diagnostic Formulation Developing the Treatment Plan Documenting the Client’s Progress
38	"ASSESSMENT" ASSESSMENT The following areas will be included as appropriate as part of a comprehensive client record: Relevant physical health conditions reported by the client will be prominently identified and updated as appropriate. Presenting problems and relevant conditions affecting the client’s physical health and mental health status will be documented, for example: living situation, daily activities, and social support. Documentation will describe client strengths in achieving client plan goals.
39	Documentation Standards ASSESSMENT The following areas will be included as appropriate as part of a comprehensive client record (continued): Special status situations that present a risk to client or others will be prominently documented and updated as appropriate. Documentation will 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 will be clearly documented.
40	Documentation Standards ASSESSMENT The following areas will be included as appropriate as part of a comprehensive client record (continued): A mental health history will 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 will be documented.
41	Documentation Standards ASSESSMENT The following areas will be included as appropriate as part of a comprehensive client record (continued): Documentation will include past and present use of tobacco, alcohol, and caffeine, as well as illicit, prescribed and over the counter drugs. A relevant mental status examination will be documented. A five axes diagnosis from the most current DSM, or a diagnosis from the most current ICD, will be documented, consistent with the presenting problems, history, mental status evaluation and/or other assessment data.
42	Contents of an Assessment Presenting Problems identified by client Medical and Psychiatric History Cultural Aspects identified by client and/or noted by clinician Language/Interpreter Needs Social History Mental Status Exam Medical Necessity Statement Preliminary (Initial) Plan Other information you or the client thinks is important Five-Axis DSM IV Diagnosis
43	Documentation Standards DIAGNOSTIC FORUMULATION MULTI-AXIAL ASSESSMENT A multi-axial system involves an assessment on several axes, each of which refers to a different domain of information that may help the clinician plan treatment and predict outcome. There are five axes included in the DSM-IV multi-axial classification: AXIS I Clinical Disorders Other Conditions that may be a focus of Clinical Attention AXIS II Personality Disorders Mental Retardation AXIS III General Medical Conditions AXIS IV Psychosocial and Environmental Problems AXIS V Global Assessment of Functioning
44	Documentation Standards CLIENT TREATMENT PLANS Client Treatment Plans will: Have specific observable and/or specific quantifiable goals. Identify the proposed type(s) of intervention. Have a proposed duration of intervention(s). Be consistent with the diagnoses, and the focus of intervention will be consistent with the client plan goals, and there will be documentation of the client’s participation and agreement with the plan.
45	Documentation Standards SIGNATURE REQUIREMENTS Client Plans will be signed (or electronic equivalent) by: The person providing the service(s), or The person representing a team or program providing services, or A person representing the MHP providing services.
46	Documentation Standards SIGNATURE REQUIREMENTS (Continued) When the client plan is used to establish that services are provided under the direction of an approved category of staff, a co-signature is NOT required: a physician (or physician extender) a licensed/waivered psychologist a licensed/registered social worker a licensed/registered Marriage, Family and Child Counselor or a Registered Nurse (MSN with Psych. + experience) .
47	Documentation Standards Mental Health Progress Notes All entries in the client record will include: Date of service delivery (00/00/00); Identify the type of MH service delivered; Location of Service; Duration/Length of Service in minutes (with sufficient documentation to justify the time expended); Signature of the person providing the service (or electronic equivalent) and co-signature, if applicable; Service provider’s professional degree, licensure, job title and; Relevant identification number, if applicable.
48	Documentation Standards Progress Notes Content Client encounters, including relevant clinical decisions and interventions. Descriptions of: Mental Health Symptoms Treatment interventions. For example, progress or attempts at progress by both the client and service staff (forward the established personal milestones or other relevant treatment objectives). Responses reflective of the Treatment Plan problem, goals and objectives. Services related to the diagnosis, signs and symptoms established goals, and expressed in terms of changes in the individual’s functioning. If there is little progress, a clear explanation of the limited progress must be included. Follow-up care.
49	Documentation Standards Progress Notes Content Staff should be aware of the role in the reduction of a beneficiary’s mental health disability and/or improvement and report this information in the Progress Note. Behavior: What specific behavior is the client displaying? If the client expresses any type of feeling and/or emotions, please explain. If the client is being unsafe, explain how the client is being unsafe. What is the client’s target behavior? Connect the situation to the client’s behavioral goals. Discuss behavioral issues of concern or significance.
50	Documentation Standards Progress Notes Content Intervention Discuss staff’s intervention(s). What has staff done to help the client process through the identified behavioral issue? Discuss staff’s counseling and/or training interventions in detail. Be specific and refer to the client’s goals/desired results/personal milestones. Make sure your interventions are justifiable. Discuss the sequence of interventions that has been applied/utilized. Did you need additional assistance from colleagues, supervisors, etc.? Discuss issues of concern or significance.
51	Documentation Standards Progress Notes Content Response What is the client’s response to your counseling/intervention? The result may be good or bad. How did the client respond? Discuss any need for follow-up or client monitoring if follow-up is necessary. Write it in the Progress Notes and make sure follow-up happens. Make sure ALL follow-up work is also charted and reference the Progress Note (date, type of Progress Note, and the referring staff person. Discuss issues of concern or significance.
52	Documentation Standards Progress Notes Content For GROUP therapy/rehabilitation, a Progress Note must be written for each beneficiary. Summary of behavioral health goals/purpose of the group session. Focus and report on the beneficiary’s group interaction and involvement. Do not use the names of other beneficiaries in the Progress Note.
53	Documentation Standards Basic Charting Guidelines MUST BE LEGIBLE Use black ink ONLY All signatures require a date (00/00/00). All documentation requires the authorized signature and discipline/title. Errors: Never use correction tape, white-out, yellow-out, (correction fluid), etc. If you make an error, draw one (1) line through the error and initial.
54	Documentation Standards Basic Charting Guidelines Only universal and county designated acronyms are accepted. Do not use the name of other client(s) in the charting. Do not “rubber stamp” your verbiage. Always attempt to obtain the client’s signature where indicated. If the client is unable or unwilling to sign, note it on the signature line, date it, and document why the client refused to sign or note inability to sign.
55	Exercise Objectives achieved?