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Documentation in Individual/Group Practitioner Medical Record.

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1 Documentation in Individual/Group Practitioner Medical Record

2 Important Provider Information can be located at: ValueOptions-Maryland; “For Providers”; “Provider Information” – Claims/Finance – Clinical/Utilization Management – Compliance (VO Audit Tools) ValueOptions-Maryland; “For Providers”; “Provider Alerts” – DHMH Provider Alerts – ValueOptions Provider Alerts ValueOptions-Maryland; “For Providers”; “Provider Manual” – Service Descriptions – Medical Necessity Criteria for Use by Maryland PMHS 2

3 Webinar Objectives Participants will be able to: Locate relevant information pertaining to Individual/Group Practices on the ValueOptions-Maryland website Learn who is authorized to serve as an Individual Practitioner under the PMHS Identify COMAR citations related to Individual Practitioners Identify the required elements of a consumer medical record

4 Definitions MENTAL HEALTH PROFESSIONAL MENTAL HEALTH PROFESSIONAL: an individual who is licensed, certified, or otherwise legally authorized to provide the mental health service: under Health Occupations Article, Annotated Code of Maryland; or in the state where the service is rendered. COMAR B (42) PROFESSIONAL COUNSELOR PROFESSIONAL COUNSELOR: an individual who is certified or licensed and legally authorized to practice as a professional counselor: under Health Occupations Article, Annotated Code of Maryland; or in the state where the service is rendered. COMAR B (55) PSYCHIATRIST PSYCHIATRIST: a physician who: is certified in psychiatry by the American Board of Psychiatry and Neurology; or has completed the minimum educational and training requirements to be qualified to take the Board of Psychiatry and Neurology examination for certification in psychiatry. COMAR B (42)

5 Definitions PSYCHOLOGIST PSYCHOLOGIST: an individual who is licensed and legally authorized to practice as a psychologist: under Health Occupations Article, Annotated Code of Maryland; or in the state where the service is rendered. COMAR B (61) SOCIAL WORKER SOCIAL WORKER: an individual who is licensed and legally authorized to practice as a social worker: under Health Occupations Article, Annotated Code of Maryland; or in the state where the service is rendered. COMAR B (78)

6 Definitions See COMAR B (7) (a-i) "Individual practitioner" means: CERTIFIED REGISTERED NURSE PRACTITIONER—PSYCHIATRIC A CERTIFIED REGISTERED NURSE PRACTITIONER—PSYCHIATRIC (CRNP—P) who is: Licensed and legally authorized to practice as a certified registered nurse practitioner—psychiatric in the state in which the service is rendered to perform independently the services set forth in COMAR ; and Certified by the Maryland Board of Nursing or an equivalent board of nursing in another state as a certified registered nurse practitioner with a specialty in psychiatry pursuant to COMAR and demonstrates, by training and experience, the competency to provide the mental health services;

7 Definitions (Individual Practitioner-continued) PHYSICIAN A PHYSICIAN who: Is licensed and legally authorized to practice as a physician in the state in which the service is rendered, and demonstrates, by training and experience, the competency to provide mental health services; PROFESSIONAL COUNSELOR A PROFESSIONAL COUNSELOR who is licensed and legally authorized to practice as a clinical professional counselor in the state in which the service is rendered;

8 Definitions (Individual Practitioner-continued) PSYCHOLOGIST A PSYCHOLOGIST who: Is licensed and legally authorized to practice as a psychologist in the state in which the service is rendered, and Demonstrates, by training and experience, the competency to provide mental health services; PSYCHOLOGY ASSOCIATE A PSYCHOLOGY ASSOCIATE who is authorized by the Maryland Board of Examiners of Psychologists to practice as a psychology associate and demonstrates, by training and experience, the competency to provide mental health services; or SOCIAL WORKER A SOCIAL WORKER who is licensed and legally authorized to practice as a clinical social worker in the state in which the service is rendered.

9 Staffing Requirements/Limitations See DHMH/MHA October,2008 Compliance with Medicaid Requirements and Billing the PMHS DISALLOWED ARE NOT The practice of employing graduate-level clinicians and receiving reimbursement for clinical services under the Public Mental Health System (PMHS) is DISALLOWED. LCSWs, LGSWs, and LGPCs cannot practice independently and ARE NOT considered “individual practitioners” under MHA regulations. NO CASE RATE The fee schedule as specified in COMAR A for treatment services in part, distinguishes between Outpatient Mental Health Center (OMHC) case rates and the case rates of LCSW-Cs and LCPCs. There is NO CASE RATE for graduate level clinicians nor licensed certified social workers in individual practitioner settings. In summary, only licensed mental health professionals authorized to practice independently may provide mental health services and receive reimbursement in the PMHS.

10 Individual Practitioner Regulations Licensed Social Workers (LCSW) COMAR COMAR Licensed Counselors (LCPC) COMAR COMAR Psychologists (Ph.D.) COMAR All Individual Practitioners: COMAR H & I

11 Medical Record Content Informed Consent for Treatment Comprehensive Assessment Treatment Planning Contact Note Documentation Referrals/Collaboration (LCPC, PhD) 11

12 Consent for Treatment See COMAR H (1) (a); LCSW: COMAR A (1-4); LPC: COMAR A (5-6); LPC: COMAR A (5); Ph.D: COMAR C (2) Consent for services is documented by signature of the consumer or, when applicable, legal guardian. In instances when this is not possible, the program shall document the reasons why the individual cannot give written consent; verify the individual’s verbal consent; and document periodic attempts to obtain written consent. Apprise the client of the risks, opportunities, and obligations associated with services available to the client;

13 Consent for Treatment—Continued The estimated cost of treatment; Make the fee for service clear, maintain adequate financial records, and confirm arrangements for financial reimbursement with the client; Per COMAR A (6) a provider shall accept payment by the Program as payment in full for covered services rendered and make no additional charge to any person for covered services. Per an April 14, 2004 DHMH memorandum entitled Billing Medicaid Recipients for Missed Appointments, “…current federal policies prohibits providers from billing Medicaid recipients for any missed appointments. The Centers for Medicare and Medicaid Services (CMS) has recently confirmed this policy to the Department”.

14 Consent for Treatment—Continued The right of a client to withdraw from treatment at any time, including the possible risks that may be associated with withdrawal; and The right of a client to decline treatment, if part or all of the treatment is to be recorded for research or review by another person

15 Consent for Treatment—Continued MINOR CONSUMERS In instances of MINOR CONSUMERS who are under the care and custody of an individual other than the parent (i.e. extended family member, DSS, foster parent), it is strongly recommended that legal documentation in the form of court orders or custody agreements be obtained and included as part of the medical record. Additionally, if consumers are court ordered to mental health treatment, it is recommended that a copy of the court order or correspondence from the probation officer should be obtained and included as part of the medical record. The treating clinician or individual facilitating the consumer’s admission should also witness consumer/parent/guardian signature via his/her dated signature on the consent.

16 Comprehensive Assessment Refer to Maryland Medical Necessity Criteria: Level of Care VI: Outpatient Services ICD-9 Crosswalk and PMHS Diagnoses-February, 2012 for guidance regarding ICD-9 Codes that are reimbursable by the PMHS pursuant to COMAR and MNC for outpatient services The comprehensive assessment includes the: Individual or family’s presenting problem; Individual or family’s history Individual’s diagnosis; and Rationale for the diagnosis

17 Comprehensive Assessment—Continued For best practice, the assessment should also include: substance abuse history (if any), mental status exam, a review of diagnosis by a physician if an organic determinant is involved or treatment with medication is indicated.

18 Comprehensive Assessment—Continued For best practice, the assessment for children should also include: level of functioning and availability of family and other social supports, developmental history, educational history and current placement, home environment, evaluation of the current family status, including legal custody status, development of motor/language/self-care skills and history, if any, of substance abuse, physical/sexual abuse, out of home placement, involvement of the local Department of Social Services or the Department of Juvenile Services.

19 Treatment Planning See LCSW: COMAR A (5) (a-b); LPC: COMAR B (8) (a-e) and COMAR A (1) (a); PhD: COMAR H (1) (c) INDIVIDUALIZED TREATMENT PLAN The record contains an INDIVIDUALIZED TREATMENT PLAN that includes the: problems, needs, strengths, goals that are measurable; interventions that are medically necessary; signatures of the individual, or if the individual is a minor, the guardian, and the treating mental health professional. For best practice, treatment plan reviews should be updated to reflect consumer progress in treatment. The plan should reflect any referrals/collaborations with outside agencies; goal changes based on a review of progress; changes in treatment strategies; and changes in diagnosis, if any.

20 Contact Notes See COMAR H (2); LCSW: COMAR A (5) (b-c), COMAR B (5) (c-d); LPC: COMAR B (9); PhD: COMAR C (2) The contact note shall include: Date of service; Start time and end time; Location; Summary of interventions provided; and The treating mental health professional’s signature and date of service. For best practice, the contact note should also include: chief medical complaint/reason for the visit; consumer’s mental status; the delivery of services specified by the ITP; a brief description of the service provided; the plan for changes in treatment (if any); the consumer’s progress towards goals

21 Referral/Collaboration See PhD: COMAR C (2); LCPC: COMAR B (8) (e) Ph.Ds. For Ph.Ds.– The consumer’s original test data and results and the results of any formal consultations with other professionals is documented in the record. LCPCs For LCPCs– When clinically indicated, the clinician has referred the consumer to additional services and/or collaborated with outside agencies. The clinician has documented the consumer declining any potential referrals for additional services. The clinician documents efforts to link the consumer to additional services.

22 2013 CPT Code Changes The American Medical Association (AMA) released major changes to the Current Procedural Terminology (CPT ® ) codes. The new code set applies to all services provided on or after January 1, All provider disciplines are impacted (psychiatrists, psychologists, social workers, licensed professional counselors and all other behavioral health providers that use CPT codes). ValueOptions and all other third party insurers will need to clearly define codes for billing and payment practices utilizing the 2013 CPT code book.

23 2013 CPT Code Changes Effective, January 1, 2013 providers must convert to using the new codes for billing dates of service on or after January 1, Several CPT codes will remain the same (i.e , 90846, 90847, 90849, 90853). However, several other CPT codes are now retired (i.e , 90862, 90857).

24 2013 CPT Code Changes Additionally, psychiatrists and other physicians must use Evaluation & Management (E/M) codes 992xx with an ‘add-on’ code if psychotherapy is performed. Initial Evaluation with medical services is now 90792; without medical services is now If initial evaluation code or is of “interactive complexity”, appropriate add-on code (i.e ) must be used. Interactive code may be used with E/M only when add-on psychotherapy codes are used refers to Psychotherapy for Patient in Crisis—60 minutes refers to Crisis beyond 60 minutes, per each additional 30 minutes.

25 2013 CPT Code Changes, Medical Record Documentation &Provider Audits ValueOptions ® and MHA have begun reviewing the billing patterns of the new E/M and crisis management CPT codes. If a review of claims since January 1, 2013 shows that an agency is an outlier in the use of 99213, 99214, 99215, 90839, and code(s), for example, that agency may be subject to audit within the next 6 months. Providers must ensure that all billed services to the PMHS have the required documentation. If the current billing pattern of the outlier code(s) starts to trend down, a previously identified agency may be removed from the potential audit list.

26 2013 CPT Code Changes For an exhaustive list of CPT code changes and resources for understanding these changes, refer to: American Academy of Child & Adolescent Psychiatry  American Psychiatric Association  American Medical Association practice/coding-billing-insurance/cpt/cpt-changes-workshops.page  Purchase the CPT® 2013 Professional Edition: https://catalog.ama-assn.org/Catalog/?_requestid=  CMS Evaluation and Management Services Guide https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network- MLN/MLNProducts/downloads/eval_mgmt_serv_guide-ICN pdf  The National Council for Behavioral Health Fact Sheet

27 2013 CPT Code Changes For an exhaustive list of CPT code changes and resources for understanding these changes, refer to:  The ValueOptions 2013 CPT Code Changes Webinars  er_Webinar_Calendar.pdf er_Webinar_Calendar.pdf  ValueOptions Spotlight Section:   ValueOptions Network Specific Page: 

28 Best Practice Review ASSESSMENT Provide more detailed ASSESSMENT information when discussing consumer’s presenting problem, symptoms, and behaviors exhibited or observed. Elaborate on the consumer’s moderate to severe areas of impairment. GOALS Develop treatment plan GOALS that are consumer specific. Treatment plan reviews should reflect any goal modifications, updates, and consumer progress.

29 Best Practice Review CONTACT NOTES Create CONTACT NOTES that in part, reflect the chief medical complaint/reason for the visit, consumer’s mental status, the delivery of services specified by the ITP, a brief description of the services provided, the plan for changes in treatment (if any), the consumer’s progress towards goals, and a legible signature with job title with credentials. GROUP CONTACT NOTES GROUP CONTACT NOTES should reference consumer’s level of participation in group activities and reflect description of services and relatedness of the group to the consumer’s treatment goals.

30 Pending COMAR Changes Below are proposed changes in the documentation language for individual providers: Progress notes for each face-to-face contact including: Date of service; Reason for service; Start time and end time; Location; Summary of interventions provided; Progress toward goals ; and The treating mental health professional’s signature and date of service.

31 Thank You Presented by… Allison Smith-Holness, LCSW Quality Management Clinical Record/Provider Auditor ValueOptions—Maryland Office Phone: (410) Office Fax: (877)


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