Presentation on theme: "1 CALIFORNIA CODE OF REGULATIONS Title 22 Drug Medi-Cal Section 51341.1-effective 6/25/14."— Presentation transcript:
1 CALIFORNIA CODE OF REGULATIONS Title 22 Drug Medi-Cal Section effective 6/25/14
PRESENTATION OUTLINE I. Admission/Physical Exam II. Treatment Planning III. Counseling Sessions IV. Progress Notes V. Continuing Services VI. Discharge VII. Additional Requirements 2
DMC Background Drug 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 3
DRUG MEDI-CAL SUD TREATMENT SERVICE MODALITIES Outpatient Drug Free (ODF) ODF Regular and Perinatal Day Care Habilitative (DCH) DCH EPSDT and Perinatal Perinatal Residential Substance Abuse Naltrexone Narcotic Treatment Programs will not be addressed in this presentation 4
5 JOB ONE! Know and follow the regulations WHY? Clients Funding Did I say Clients?
6 Establish Medical Necessity (physician) Establish and maintain individual Beneficiary record Provide treatment services Document, document, document Submit claims for reimbursement AND The Double Top Secret Magic Passwords to Success Follow the TIMELINES in the regs PROVIDER RESPONSIBILITIES
PROVIDER DON’TS Do 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 7
Almost everything you want to know about DMC admission criteria 8 ADMISSION TO TREATMENT
For each Beneficiary the provider shall complete: Personal history Medical history Substance use history Assessment of the physical condition 9 ADMISSION CRITERIA Section (h)
INTAKE /ASSESSMENT The Basis for Establishing Medical Necessity The evaluation or analysis of the cause or nature of the disorders listed below using DSM codes: 10 Mental Emotional Psychological Behavioral and Substance Use Section (b)(13) The assessment of treatment needs to provide medically necessary treatment services by a physician includes May also include a physical examination and laboratory testing by staff lawfully authorized to provide such services
11 ADDITIONAL PERINATAL REQUIREMENTS Sections 50260, 51303, (c)(1), (g)(1)(A)(iii) Beneficiary must be eligible for and received Medi-Cal during the last month of pregnancy Must 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 pregnancy Eligibility ends on the last day of the month in which the 60 th day occurs
PHYSICAL EXAM REQUIREMENTS 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 OR Include obtaining a physical examination as a treatment plan goal WHY IS A FOCUS ON PHYSICAL HEALTH IMPORTANT? 12 Section (h)(1)(A)(iv)(a)(b)&(c)
PHYSICAL HEALTH AND SUD SUD complicates and leads to serious health conditions Increased 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 patients Over half of people w/SUD have another health condition SUD has negative impact on mental health and behavior Risk-taking behavior creates high risk for communicable diseases and other serious injury People w/SUD incur 2x-3x the total medical expenses of people who do not have SUD 13
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. MEDICAL NECESSITY 15 Sections 51303, (h)(1)(A)(v) (vi) Sections 51303, (h)(1)(A)(v) (vi)
TREATMENT PLANNING 16
17 TREATMENT PLANNING Section (h)(2) The treatment plan for each Beneficiary must: Be individualized Be based on the information obtained during the intake and assessment process Attempt 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 MUST INCLUDE THE FOLLOWING EIGHT (8) ELEMENTS… Section (h)(2)(A)(i) 1)A statement of the problems to be addressed 2)Goals to be reached which address each problem 3)Action steps which will be taken by the provider, and/or Beneficiary to accomplish identified goals 4)Target dates for the accomplishment of action steps and goals
19 EIGHT ELEMENTS Cont. Section (h)(2)(A)(i) 5)A description of the services, including the type and frequency of counseling to be provided Group counseling must be a specific number of sessions over a specific period of time If individual counseling is planned, it must be on the treatment plan 6) The assignment of a primary therapist or counselor 7) The Beneficiary’s DSM code diagnosis
20 LAST BUT VERY IMPORTANT 8) 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. AND If 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.
Therapist/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. 21 INITIAL TREATMENT PLAN TIMELINES Section (h)(2)(A)(ii)
Therapist/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. 22 UPDATED TREATMENT PLAN TIMELINES Section (h)(2)(A)(iii)
23 BENEFICIARY CONTACT REQUIREMENTS Section (d)(2)(A) (h)(4)(A) Minimum of two provider/beneficiary contacts per 30 day period (for ODF – 2 group counseling sessions) Requirement may be waived by the physician if: a)Fewer contacts are clinically appropriate; b)The Beneficiary is making progress towards treatment plan goals
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. 24
Covered So Far I. Admission/Physical Exam II. Treatment Planning III. Counseling Sessions IV. Progress Notes V. Continuing Services VI. Discharge VII. Additional Requirements 25
26 GROUP COUNSELING Section (b)(11)
Must be conducted in a confidential setting Must 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 session A typed or printed name and signature of counselor(s) facilitating session (certifying accuracy and completeness) The date of the counseling session The start and end times of the counseling session The topic of the counseling session 27 GROUP COUNSELING SESSIONS Sections (b)(11), (g)(2)
REQUIREMENTS BY MODALITY Section (b)(11) ODF Must have at least four (4) and no more than ten (10) participants in any one group counseling session In order to bill DMC, at least one of the four (4) to ten (10) participants must be a DMC Beneficiary 28
Must have at least two (2) and no more than twelve (12) participants in any one group counseling session In order to bill DMC, at least one of the two (2) to twelve (12) participants must be a DMC beneficiary 29 REQUIREMENTS BY MODALITY Section (b)(11 ) DCH
A Beneficiary that is under the age of 18 years cannot participate in group counseling sessions with any participants that are 18 years or older UNLESS The group counseling sessions are held at a provider’s certified school site 30 AGE LIMITS
31 INDIVIDUAL COUNSELING
32 INDIVIDUAL COUNSELING Section (b)(10) Must be face to face contact at a DMC certified location to bill for the service No home visits, no hospital visits, no telephone contacts
34 COLLATERAL SERVICES COUNSELING Section (b)(4) Face-to-face session With persons significant in the life of the Beneficiary Personal, not professional, relationships Focusing on the treatment needs of the Beneficiary Supporting the achievement of the Beneficiary’s treatment goals Beneficiary does not have to attend
35 CRISIS INTERVENTION COUNSELING Section (b)(7) Face-to-face contact with a Beneficiary in crisis Crisis is an actual relapse, or Unforeseen event or circumstance causing an imminent threat of relapse Services shall: Focus on alleviating crisis problems, and Limited to stabilization of the emergency
PROGRESS NOTES 36 Counselor/therapist must legibly print, sign and date the progress note!
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 session 37 ODF Section (h)(3)(A)
At 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 session 38 DCH/PERINATAL RESIDENTIAL Section (h)(3)(B)
39 Progress notes should tell the beneficiary’s treatment story
Covered So Far I. Admission/Physical Exam II. Treatment Planning III. Counseling Sessions IV. Progress Notes V. Continuing Services VI. Discharge VII. Additional Requirements 40
To treat or not to treat, That is the Question 41 CONTINUING TREATMENT
MEDICAL NECESSITY OF CONTINUED SERVICES Section (h)(5)(A)(ii MEDICAL NECESSITY OF CONTINUED SERVICES Section (h)(5)(A)(ii) 42 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.
CONTINUED SERVICES JUSTIFICATION 43 The physician must document the medical necessity determination to continue services based on review of the Beneficiary’s: Personal, medical and substance use history Most recent physical exam Treatment plan goals Progress in treatment (progress notes) Therapist/counselor recommendations Prognosis
45 DISCHARGE PLAN Section (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’s Relapse triggers Support plan The 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 RELAPSE TRIGGERS Section (b)(26)
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. 47
DISCHARGE SUMMARY Section (h)(6)(B) 48 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 dates Reason for discharge Narrative summary of treatment episode Beneficiary’s prognosis
49 FAIR HEARING Section (p) Providers shall inform Beneficiaries of their right to a fair hearing related to: Denial Involuntary discharge Reduction in DMC services As these relate to their eligibility or benefits.
50 FAIR HEARING Section (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 take The reason for the intended action A citation of the specific regulation(s) supporting the intended action Informing the Beneficiary of his/her right to a fair hearing for the purpose of appealing the intended action Informing the Beneficiary that the provider must continue treatment only if the beneficiary appeals in writing within 10 days of the notice Must include the address where the request for a fair hearing must be submitted
Additional Requirements 51
MULTIPLE SERVICES SAME DAY Section ODF Return visit shall not create a hardship on Beneficiary Document time of day of each visit Progress 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 service The provider must complete the DHCS MC 7700 form and place in Beneficiary record Or 52
DCH The return visit shall clearly document a crisis service Crisis services shall be documented in the progress notes Provider must complete the DHCS MC 7700 form and place in Beneficiary record 53 MULTIPLE SERVICES SAME DAY Section
54 SHARE OF COST Section (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.
Contact DHCS Provider Enrollment with application and certification inquiries as well as programmatic changes such as relocation or administration adjustments For additional Title 22 Regulation information E-DMCProgramIntegrity.aspx 55 ADDITIONAL INFORMATION
56 Questions for this presentation will be collected and responded to at a later date.