Presentation on theme: "DRUG MEDI-CAL TITLE 22 TRAINING"— Presentation transcript:
1 DRUG MEDI-CAL TITLE 22 TRAINING CALIFORNIA CODE OF REGULATIONSTitle 22 Drug Medi-CalSection effective 6/25/14
2 DRUG MEDI-CAL TITLE 22 TRAINING PRESENTATION OUTLINEAdmission/Physical ExamTreatment PlanningCounseling SessionsProgress NotesContinuing ServicesDischargeAdditional Requirements
3 DMC 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
4 DRUG 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
5 DRUG MEDI-CAL TITLE 22 TRAINING JOB ONE!Know and follow the regulationsWHY?ClientsFundingDid I say Clients?
6 PROVIDER 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
7 PROVIDER 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
8 ADMISSION TO TREATMENT Almost everything you want to know about DMC admission criteriaADMISSION TO TREATMENT
9 DRUG MEDI-CAL TITLE 22 TRAINING For each Beneficiary the provider shall complete:Personal historyMedical historySubstance use historyAssessment of the physical conditionADMISSION CRITERIASection (h)
10 DRUG 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
11 DRUG 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
12 PHYSICAL 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?
13 PHYSICAL 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
14 Physical Examination Waivers are no longer an option for Drug Medi-Cal Programs
15 DRUG 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.
17 DRUG 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.
18 DRUG 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
19 EIGHT 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
20 DRUG 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.
21 INITIAL 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)
22 UPDATED 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)
23 DRUG 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
24 BENEFICIARY 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.
25 DRUG MEDI-CAL TITLE 22 TRAINING Covered So FarAdmission/Physical ExamTreatment PlanningCounseling SessionsProgress NotesContinuing ServicesDischargeAdditional Requirements
26 DRUG MEDI-CAL TITLE 22 TRAINING GROUP COUNSELINGSection (b)(11)
27 GROUP 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)
28 REQUIREMENTS 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
29 REQUIREMENTS 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
30 A 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
31 INDIVIDUAL COUNSELING DRUG MEDI-CAL TITLE 22 TRAININGINDIVIDUAL COUNSELING
32 DRUG 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
33 INDIVIDUAL COUNSELING LIMITS FOR ODF Intake/AssessmentTreatment PlanningDischarge PlanningCollateralCrisis
34 DRUG 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
35 DRUG 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
36 PROGRESS NOTESCounselor/therapist must legibly print, sign and date the progress note!
37 DRUG 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)
38 DCH/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)
39 DRUG MEDI-CAL TITLE 22 TRAINING Progress notes should tell the beneficiary’s treatment story
40 DRUG MEDI-CAL TITLE 22 TRAINING Covered So FarAdmission/Physical ExamTreatment PlanningCounseling SessionsProgress NotesContinuing ServicesDischargeAdditional Requirements
41 To treat or not to treat, That is the Question CONTINUING TREATMENT
42 MEDICAL 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.
43 CONTINUED 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
45 DRUG 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.
46 DRUG MEDI-CAL TITLE 22 TRAINING RELAPSE TRIGGERSSection (b)(26)
47 SUPPORT 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.
48 DISCHARGE 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
49 DRUG 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.
50 DRUG 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
52 DRUG 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
53 DRUG 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
54 DRUG 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.
55 ADDITIONAL 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
56 DRUG MEDI-CAL TITLE 22 TRAINING Questions for this presentation will be collected and responded to at a later date.