Presentation on theme: "DRUG MEDI-CAL TITLE 22 TRAINING"— Presentation transcript:
1DRUG MEDI-CAL TITLE 22 TRAINING CALIFORNIA CODE OF REGULATIONSTitle 22 Drug Medi-CalSection effective 6/25/14
2DRUG MEDI-CAL TITLE 22 TRAINING PRESENTATION OUTLINEAdmission/Physical ExamTreatment PlanningCounseling SessionsProgress NotesContinuing ServicesDischargeAdditional Requirements
3DMC BackgroundDrug Medi-Cal (DMC) is a drug and alcohol treatment program funded through the federal Medicaid program The services provided must be contained in an approved State Medicaid Plan (approved by CMS) The California Federal Financial Participation (FFP) is 50% federal funds and 50% state or local funds The primary regulations that govern DMC are contained in Title 22, Sections (program requirements), (claim submission requirements) and (reimbursement rates and requirements) Program Integrity emergency regulations for Section became effective on 6/25/14
4DRUG MEDI-CAL TITLE 22 TRAINING DRUG MEDI-CAL SUD TREATMENT SERVICE MODALITIESOutpatient Drug Free (ODF)ODF Regular and PerinatalDay Care Habilitative (DCH)DCH EPSDT and PerinatalPerinatal Residential Substance AbuseNaltrexoneNarcotic Treatment Programs will not beaddressed in this presentation
5DRUG MEDI-CAL TITLE 22 TRAINING JOB ONE!Know and follow the regulationsWHY?ClientsFundingDid I say Clients?
6PROVIDER RESPONSIBILITIES Establish Medical Necessity (physician)Establish and maintain individual Beneficiary recordProvide treatment servicesDocument, document, documentSubmit claims for reimbursementANDThe Double Top Secret Magic Passwords to SuccessFollow the TIMELINES in the regsPROVIDER RESPONSIBILITIES
7PROVIDER DON’TSDo not sign patient names to any document or sign-in sheet Do not sign any document using the Medical Director’s or anyone else’s signature (no signature stamps allowed) Do not intentionally submit erroneous billings Do not falsify any Medi-Cal record/document (e.g., progress notes, treatment plans, etc.) Do not back date/forward date any signature Sign blank documents Do not allow unqualified staff to provide services
8ADMISSION TO TREATMENT Almost everything you want to know about DMC admission criteriaADMISSION TO TREATMENT
9DRUG MEDI-CAL TITLE 22 TRAINING For each Beneficiary the provider shall complete:Personal historyMedical historySubstance use historyAssessment of the physical conditionADMISSION CRITERIASection (h)
10DRUG MEDI-CAL TITLE 22 TRAINING INTAKE /ASSESSMENTThe Basis for Establishing Medical NecessityThe evaluation or analysis of the cause or nature of the disorders listed below using DSM codes:Section (b)(13)The assessment of treatment needs to provide medically necessary treatment services by a physician includesMental Emotional Psychological Behavioral and Substance UseMay also include a physical examination and laboratory testing by staff lawfully authorized to provide such services
11DRUG MEDI-CAL TITLE 22 TRAINING ADDITIONAL PERINATAL REQUIREMENTSSections 50260, 51303, (c)(1), (g)(1)(A)(iii)Beneficiary must be eligible for and received Medi-Cal during the last month of pregnancyMust have medical documentation that substantiates the Beneficiary’s pregnancy and last day of pregnancy.Rate is applicable during pregnancy and for the 60-day postpartum period beginning on the last day of pregnancyEligibility ends on the last day of the month in which the 60th day occurs
12PHYSICAL EXAM REQUIREMENTS DRUG MEDI-CAL TITLE 22 TRAININGPHYSICAL EXAM REQUIREMENTSSection (h)(1)(A)(iv)(a)(b)&(c)A physical examination can be conducted by the program’s physician, registered nurse practitioner or physician’s assistant, within thirty (30) days of admission OR Physician can review documentation of most recent (within 12 months) physical examination Include obtaining a physical examination as a treatment plan goal WHY IS A FOCUS ON PHYSICAL HEALTH IMPORTANT?
13PHYSICAL HEALTH AND SUD SUD complicates and leads to serious health conditionsIncreased risk of pregnancy complications, cancer, and gastrointestinal, cardiovascular, pulmonary, renal, hematological, gynecological and metabolic problems.Arthritis, asthma, hypertension and ischemic heart disease – 2x more prevalent in SUD patientsOver half of people w/SUD have another health conditionSUD has negative impact on mental health and behaviorRisk-taking behavior creates high risk for communicable diseases and other serious injuryPeople w/SUD incur 2x-3x the total medical expenses of people who do not have SUD
14Physical Examination Waivers are no longer an option for Drug Medi-Cal Programs
15DRUG MEDI-CAL TITLE 22 TRAINING MEDICAL NECESSITYSections 51303, (h)(1)(A)(v) (vi)The physician shall document the basis for the DSM code diagnosis indicating medical necessity in the Beneficiary’s individual record within thirty (30) calendar days of the Beneficiary’s date of admission to treatment.
17DRUG MEDI-CAL TITLE 22 TRAINING TREATMENT PLANNINGSection (h)(2)The treatment plan for each Beneficiary must:Be individualizedBe based on the information obtained during the intake and assessment processAttempt to engage the Beneficiary to meaningfully participate in the preparation of the initial treatment plan and updated treatment plans – Bene must sign! If Bene refuses, documentation of strategy to engage Bene must be added to Tx plan.Be legible – including staff names; names of counselors, therapists, physicians, etc. Must sign and date.
18DRUG MEDI-CAL TITLE 22 TRAINING MUST INCLUDE THE FOLLOWING EIGHT (8) ELEMENTS…Section (h)(2)(A)(i)A statement of the problems to be addressedGoals to be reached which address each problemAction steps which will be taken by the provider, and/or Beneficiary to accomplish identified goalsTarget dates for the accomplishment of action steps and goals
19EIGHT ELEMENTS Cont. Section 51341.1(h)(2)(A)(i) A description of the services, including the type and frequency of counseling to be providedGroup counseling must be a specific number of sessions over a specific period of timeIf individual counseling is planned, it must be on the treatment plan6) The assignment of a primary therapist orcounselor7) The Beneficiary’s DSM code diagnosis
20DRUG MEDI-CAL TITLE 22 TRAINING LAST BUT VERY IMPORTANT8) If the Beneficiary has not had a physical examination within the twelve (12) month period prior to the date of admission, a goal that the Beneficiary have a physical examination must be added to the treatment plan.ANDIf documentation of a Beneficiary’s physical examination, which was performed during the prior twelve (12) months, indicates a significant medical illness, a goal that the Beneficiary obtain appropriate treatment for the illness must be added to the treatment plan.
21INITIAL TREATMENT PLAN TIMELINES Section 51341.1(h)(2)(A)(ii) DRUG MEDI-CAL TITLE 22 TRAININGTherapist/Counselor - shall complete, sign and date the initial treatment plan within thirty (30) calendar days of the admission to treatment date. Beneficiary – shall review, approve, sign and date the initial treatment plan, indicating whether the beneficiary participated in preparation of the plan, within thirty (30) calendar days of the admission to treatment date. Physician - shall review the initial treatment plan to determine whether the services are medically necessary, sign, and date the initial treatment plan within fifteen (15) calendar days of signature by the therapist or counselor.INITIAL TREATMENT PLAN TIMELINES Section (h)(2)(A)(ii)
22UPDATED TREATMENT PLAN TIMELINES Section 51341.1(h)(2)(A)(iii) DRUG MEDI-CAL TITLE 22 TRAININGTherapist/Counselor shall complete, sign and date the updated treatment plan no later than ninety (90) calendar days after signing the initial treatment plan, and no later than every ninety (90) calendar days thereafter (unless a change in problem identification or focus of treatment occurs) The Beneficiary shall review, approve, sign and date the updated treatment plan, indicating whether the Beneficiary participated in preparation of the plan within thirty (30) calendar days of signature by the therapist or counselor. The Physician shall review each updated treatment plan to determine whether the services are medically necessary and sign and date the updated treatment plan within fifteen (15) calendar days of signature by the therapist or counselor.UPDATED TREATMENT PLAN TIMELINES Section (h)(2)(A)(iii)
23DRUG MEDI-CAL TITLE 22 TRAINING BENEFICIARY CONTACT REQUIREMENTSSection (d)(2)(A) (h)(4)(A)Minimum of two provider/beneficiary contacts per day period (for ODF – 2 group counseling sessions)Requirement may be waived by the physician if:Fewer contacts are clinically appropriate;The Beneficiary is making progress towards treatment plan goals
24BENEFICIARY CONTACT Cont BENEFICIARY CONTACT Cont. Exceptions must be noted, signed and dated by the physician in the Beneficiary’s record However If the Beneficiary does not attend treatment for more than 30 days, the provider must discharge the Beneficiary.
25DRUG MEDI-CAL TITLE 22 TRAINING Covered So FarAdmission/Physical ExamTreatment PlanningCounseling SessionsProgress NotesContinuing ServicesDischargeAdditional Requirements
26DRUG MEDI-CAL TITLE 22 TRAINING GROUP COUNSELINGSection (b)(11)
27GROUP COUNSELING SESSIONS Sections 51341.1(b)(11), 51341.1(g)(2) DRUG MEDI-CAL TITLE 22 TRAININGMust be conducted in a confidential settingMust have a group sign-in sheet that includes:A typed or printed list of the Beneficiary’s names and the signature of each Beneficiary that attended the counseling sessionA typed or printed name and signature of counselor(s) facilitating session (certifying accuracy and completeness)The date of the counseling sessionThe start and end times of the counseling sessionThe topic of the counseling sessionGROUP COUNSELING SESSIONS Sections (b)(11), (g)(2)
28REQUIREMENTS BY MODALITY Section 51341.1(b)(11) DRUG MEDI-CAL TITLE 22 TRAININGREQUIREMENTS BY MODALITY Section (b)(11)ODFMust have at least four (4) and no more than ten (10) participants in any one group counseling sessionIn order to bill DMC, at least one of the four (4) to ten (10) participants must be a DMC Beneficiary
29REQUIREMENTS BY MODALITY Section 51341.1(b)(11) DCH Must have at least two (2) and no more than twelve (12) participants in any one group counseling sessionIn order to bill DMC, at least one of the two (2) to twelve (12) participants must be a DMC beneficiaryREQUIREMENTS BY MODALITY Section (b)(11) DCH
30A Beneficiary that is under the age of 18 years cannot participate in group counseling sessions with any participants that are 18 years or olderUNLESSThe group counseling sessions are held at aprovider’s certified school siteAGE LIMITS
31INDIVIDUAL COUNSELING DRUG MEDI-CAL TITLE 22 TRAININGINDIVIDUAL COUNSELING
32DRUG MEDI-CAL TITLE 22 TRAINING INDIVIDUAL COUNSELINGSection (b)(10)Must be face to face contact at a DMC certified location to bill for the serviceNo home visits, no hospital visits, no telephone contacts
33INDIVIDUAL COUNSELING LIMITS FOR ODF Intake/AssessmentTreatment PlanningDischarge PlanningCollateralCrisis
34DRUG MEDI-CAL TITLE 22 TRAINING COLLATERAL SERVICES COUNSELINGSection (b)(4)Face-to-face sessionWith persons significant in the life of the BeneficiaryPersonal, not professional, relationshipsFocusing on the treatment needs of the BeneficiarySupporting the achievement of the Beneficiary’s treatment goalsBeneficiary does not have to attend
35DRUG MEDI-CAL TITLE 22 TRAINING CRISIS INTERVENTION COUNSELINGSection (b)(7)Face-to-face contact with a Beneficiary in crisisCrisis is an actual relapse, orUnforeseen event or circumstance causing an imminent threat of relapseServices shall:Focus on alleviating crisis problems, andLimited to stabilization of the emergency
36PROGRESS NOTESCounselor/therapist must legibly print, sign and date the progress note!
37DRUG MEDI-CAL TITLE 22 TRAINING For each individual and group counseling session the therapist or counselor who conducted the counseling session shall record a progress note for each Beneficiary who participated within seven (7) calendar days of the session that includes the following: The topic of the session A description of the Beneficiary's progress on the treatment plan problems, goals, action steps, objectives, and/or referrals Information on the Beneficiary's attendance, including the date, start and end times of each individual and group counseling sessionODF Section (h)(3)(A)
38DCH/PERINATAL RESIDENTIAL Section 51341.1(h)(3)(B) DRUG MEDI-CAL TITLE 22 TRAININGAt minimum, one (1) progress note, per calendar week, should be recorded for each Beneficiary and should include: A description of the Beneficiary's progress on the treatment plan problems, goals, action steps, objectives, and/or referrals A record of the Beneficiary's attendance at each counseling session including the date, start and end times and topic of the counseling sessionDCH/PERINATAL RESIDENTIAL Section (h)(3)(B)
39DRUG MEDI-CAL TITLE 22 TRAINING Progress notes should tell the beneficiary’s treatment story
40DRUG MEDI-CAL TITLE 22 TRAINING Covered So FarAdmission/Physical ExamTreatment PlanningCounseling SessionsProgress NotesContinuing ServicesDischargeAdditional Requirements
41To treat or not to treat, That is the Question CONTINUING TREATMENT
42MEDICAL NECESSITY OF CONTINUED SERVICES Section 51341.1(h)(5)(A)(ii) No sooner than 5 months and no later than 6 months after admission, or the completion of the most recent justification, the need for continued treatment must be determined by the physician.
43CONTINUED SERVICES JUSTIFICATION The physician must document the medical necessity determination to continue services based on review of the Beneficiary’s:Personal, medical and substance use historyMost recent physical examTreatment plan goalsProgress in treatment (progress notes)Therapist/counselor recommendationsPrognosis
45DRUG MEDI-CAL TITLE 22 TRAINING DISCHARGE PLANSection (h)(6)(A)Discharge Plans must be completed in the thirty (30) calendar days prior to the last face-to-face treatment session on all Beneficiaries by the therapist/counselor.The Discharge Plan is a document developed by the counselor and the Beneficiary that identifies the Beneficiary’sRelapse triggersSupport planThe Discharge Plan must be signed by the counselor and the Beneficiary and a copy provided to the Beneficiary. The Discharge Plan will become part of the individual record.
46DRUG MEDI-CAL TITLE 22 TRAINING RELAPSE TRIGGERSSection (b)(26)
47SUPPORT PLAN Section (b)(28) A list of individuals and/or organizations and activities that can provide support and assistance to a Beneficiary to maintain sobriety.
48DISCHARGE SUMMARY Section 51341.1(h)(6)(B) When a provider has lost contact or the Beneficiary is not available for 30 days, the provider will complete a Discharge Summary that shall include:Duration of treatment as determined by admission and discharge datesReason for dischargeNarrative summary of treatment episodeBeneficiary’s prognosis
49DRUG MEDI-CAL TITLE 22 TRAINING FAIR HEARINGSection (p)Providers shall inform Beneficiaries of their right to a fair hearing related to:DenialInvoluntary dischargeReduction in DMC servicesAs these relate to their eligibility or benefits.
50DRUG MEDI-CAL TITLE 22 TRAINING FAIR HEARINGSection (p)At least 10 calendar days prior to the effective date of the intended action the provider must give the Beneficiary a written notice that includes:A statement of the action the provider intends to takeThe reason for the intended actionA citation of the specific regulation(s) supporting the intended actionInforming the Beneficiary of his/her right to a fair hearing for the purpose of appealing the intended actionInforming the Beneficiary that the provider must continue treatment only if the beneficiary appeals in writing within 10 days of the noticeMust include the address where the request for a fair hearing must be submitted
52DRUG MEDI-CAL TITLE 22 TRAINING MULTIPLE SERVICES SAME DAYSectionODFReturn visit shall not create a hardship on BeneficiaryDocument time of day of each visitProgress note shall clearly reflect that an effort to provide all services in one visit was made and the return visit was unavoidable;The return visit shall clearly document a crisis or collateral serviceThe provider must complete the DHCS MC 7700 form and place in Beneficiary recordOr
53DRUG MEDI-CAL TITLE 22 TRAINING MULTIPLE SERVICES SAME DAY SectionDCHThe return visit shall clearly document a crisis serviceCrisis services shall be documented in the progress notesProvider must complete the DHCS MC 7700 form and place in Beneficiary record
54DRUG MEDI-CAL TITLE 22 TRAINING SHARE OF COSTSection (h)(7)Except where share of cost, as defined in Section 50090, is applicable, providers shall accept proof of eligibility for Drug Medi-Cal as payment in full for treatment services rendered. Providers shall not charge fees to a Beneficiary for access to Drug Medi-Cal substance use disorder services or for admission to a Drug Medi-Cal treatment program.
55ADDITIONAL INFORMATION DRUG MEDI-CAL TITLE 22 TRAININGContact DHCS Provider Enrollment with application and certification inquiries as well as programmatic changes such as relocation or administration adjustmentsFor additional Title 22 Regulation informationADDITIONAL INFORMATION
56DRUG MEDI-CAL TITLE 22 TRAINING Questions for this presentation will be collected and responded to at a later date.