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Matching Services Documented to Services Billed for AAPS and Medicaid Funded Services By: Brian Baker, Sheree Marzka and Chris Forshee
What is documentation and why is it so important? Medical record documentation is required to record pertinent facts, findings, and observations about an individual's medical history, treatment, and outcomes. The medical record chronologically documents the treatment of the member and is an important element contributing to high quality care.
What is documentation and why is it so important? (cont. ) The medical record facilitates: n the ability of the counselor and other health care professionals to evaluate and plan the member’s immediate treatment, and to monitor his/her outcomes over time; n communication and continuity of care among counselors and other health care professionals involved in the member's care;
What is documentation and why is it so important? (cont. ) n accurate and timely claims review and payment; n appropriate utilization review and quality of care evaluations; and n collection of data that may be useful for research and education.
Federal Regulations Related to Program Integrity n Program Integrity 42 CFR Part 455 n Utilization Control 42 CFR Part 456 n Lock-In of Recipients 42 CFR Subpart B § 431. 54(e) n Provider Enrollment and Exclusion 42 CFR Part 1001& 1002
Federal Regulations Related to Program Integrity n Deficit Reduction Act n Established the Medicaid Integrity Program n National strategy to detect and prevent Medicaid fraud and abuse n CMS received funding –reaching $75 M in FFY 2009
Start and Stop Times n Every billable activity must have a start and stop time. n Start time: 2: 00 Stop time: 3: 00 Billed 4 units (15 minute increments). n Daily activity logs are a best practice but the start and stop times must match the progress note start and stop times. n Different progress notes should not have the same start and stop times for the same day.
Start and Stop Times (cont. ) n The number of units documented must match the number of units billed. n The number of units documented must match the AAPS requirements for that code (for example: n Reintegration must meet requirements listed in R 03 -707
Start and Stop Times (cont. ) Find the error(s) in the following: n n n n n 9: 30 – 10: 00 – Individual Session 10: 00 – 12: 00 – Orientation Group 1: 00 – 2: 00 – Confrontation group 2: 00 – 3: 00 – Process Group 3: 00 – 4: 00 – Treatment plan update group 4: 00 – 5: 00 – Relapse prevention 6: 30 – 7: 30 – Conflict resolution group 6: 30 – 9: 30 – AA/NA Meeting 7: 30 – 9: 30 –Family education/outside support group 8: 00 – 9: 30 – Anger Management Group
Service Codes Billed n The service code that was paid must match the documentation in the chart. n For example: n n Called to set up appointments: doctor’s appointment, psych meds, and housing consultation for member. Called member to let her know the appointment dates and times. Billed case management or PCCM (depending on funding source). Urine Analyses (UAs) are not billable as a separate service.
Service Codes Billed (cont. ) Find the error(s) in the following: n Billed H 0004 4 units n Called doctor to set up appointment on 1/15/10. Called mental health and member is scheduled for an appointment tomorrow. n 8: 00 – 8: 30 n Shannon Doe, AAPS 1/13/10
Service Codes Billed (cont. ) Find the error(s) in the following: n 1/10/10 9: 30 am – 10: 00 am: Orientation Group n Reviewed the client rules and went over what is expected from each person. There was an issue with the penalty for rule 1. Several of the clients questioned why they would be discharged for drug paraphernalia.
Service Codes Billed (cont. ) Find the error(s) in the following: n 1/10/10 9: 30 am – 10: 00 am: Orientation Group n Reviewed the facility’s grievance procedure and what clients should do if they are unhappy about something in the program.
KCPC and Chart Documentation n Documentation in the KCPC should match documentation in the member’s chart. n For example: n The clinical record says the member is doing well in group and has a positive attitude, and the KCPC notes say the same thing, or give a reason why there is a difference.
KCPC and Chart Documentation (cont. ) Find the error(s) in the following: n Assessment: Client lives with non substance abusing parents. Has a few friends who do not abuse substances. n Intake note: Client is homeless and has no social support system. All of his friends use drugs. n Progress note: Client has housing with his non substance abusing parents. Will discharge in the morning.
Units Billed n Notes should document that the member was present for the entire time for which services were billed. The units paid for should match the documentation in the clinical record.
Units Billed (cont. ) n A one hour group started 15 minutes late so it n n lasted for 45 minutes, only 3 units were billed. Member was a no show, no services billed. Member had a seizure during group, only the time the member was in group was billed. The start and stop time in the chart reflected the time the member was present in group. Member on a 2 -day pass, no services billed. Activity logs should not indicate the member is present if client was not there.
Units Billed (cont. ) The following chart should help limit rounding errors for services provided in 15 -minute increments: n Bill 1 unit if a member is seen between 8 minutes to 22 minutes n Bill 2 units if a member is seen between 23 minutes through 37 minutes n Bill 3 units if a member is seen between 38 minutes through 52 minutes n Bill 4 units if a member is seen between 53 minutes through 67 minutes n Bill 5 units if a member is seen between 68 minutes through 82 minutes n Bill 6 units if a member is seen between 83 minutes through 97 minutes n Bill 7 units if a member is seen between 98 minutes through 112 minutes n Bill 8 units if a member is seen between 113 minutes through 127 minutes
Units Billed (cont. ) Find the error(s) The following activity logs were signed indicating the client was present: n 9: 30 – 10: 00 – Orientation Group n 10: 00 – 12: 00 – Anger Management Group n 1: 00 – 2: 00 – Confrontation group n 2: 00 – 3: 00 – Individual session n 3: 00 – 4: 00 – Treatment plan update group n 4: 00 – 5: 00 – Relapse prevention
Units Billed (cont. ) Find the error(s) cont. Progress notes: n 9: 30 – 10: 00 – Community group – John was not able to attend group today due to recovering from outpatient surgery. n 10: 00 – 12: 00 – Group - John was not able to attend group today due to recovering from outpatient surgery.
Individualizing Notes n Progress notes should be individualized for the client and relate back to the treatment plan. n The client’s name should be in the progress note as well as what the specific member did/said during the group/individual session. n Progress notes describe member strengths and limitations in achieving treatment plan goals and objectives.
Individualizing Notes (cont. ) Find the error(s): n John Doe was in group and listening to the information but when asked if he would be interested in a program like this, he shared that at the current time he really needs to return to work. n Jane Doe was present for lecture. The lecture talked about when using drugs, you put yourself in multiple dangers of emotional abuse and physical abuse. Jane Doe participated in group and talked about how she had to run from people many times looking for drugs.
Individualizing Notes (cont. ) Find the error(s): n Jack Smith was in group and listening to the information but when asked if he would be interested in a program like this, he shared that at the current time he really needs to return to work. n Julie Smith was present for lecture. The lecture talked about when using drugs, you put yourself in multiple dangers of emotional abuse and physical abuse. Julie participated in group and talked about how she had to run from people many times looking for drugs.
Signatures n Notes should be signed with a complete signature by an AAPS credentialed counselor as required by the service being performed. n For example: Sign each individual entry; n If there are multiple entries on a page, sign each entry; n
Signatures (cont. ) Use full names in the signature; n If the person signing each entry is not AAPS credentialed, have the supervising AAPS credentialed person sign the daily entries. n The signature must be dated. n
Documentation n Activity logs should not be pre-signed. n Progress notes should be written after the group/individual session took place. n If this occurs, there should not be a need to cross out signatures and notes if the client was not in attendance.
Additional Tips n All entries in the record should be in blue or black ink, not pencil. n The record should not contain any white out. If corrections must be made, use a single line to strike through what was written in error so it is still visible. All corrections must be initialed and dated by the person making the correction. n Documents must be bound in the record, not on post-it-notes or loose paper.
Additional Tips n Each piece of paper should document a way to identify the client. For example, John Doe or Chart number: 0015232. n If a member has an allergy, prominently note the allergy in the chart (especially food/medication allergies) n Be sure to protect records from disasters such as a flood. n Keep records in a secure, locked location.
Quality of Care: Medications n Logs should be kept for all clients receiving medications. n There should be documentation from the prescribing provider (what, how much, how often). n If a member misses a dose, there should be a note about why. n If a member discontinues a medication, there should be a note about why. For prescription meds, there should be a doctor’s order.
Quality of Care: Referrals/Appts. n Unless there is a medical doctor on staff, requests for medical services should be documented and a referral/appointment should be made. n If mental health issues are documented, a referral should be made and documented.
Quality of Care: Referrals/Appts. (cont. ) Find the error(s) in the following: While in group, Jane Doe stated she wasn’t feeling well and requested to be taken to the hospital. The counselor suggested waiting to see how she felt at the end of group before calling 911.
Quality of Care: Suicidal/Homicidal Ideation n If a member is experiencing suicidal/homicidal ideation, an immediate referral to mental health is made n Suicidal/homicidal ideation does not occur only at the time of the assessment
Treatment Plans and Discharge Plans n Most clients are looking for: n Housing; n AA/NA, community supports; n Employment; and n Child care (when applicable).
Treatment Plans and Discharge Plans (cont. ) n Plans could also include issues specifically related to the individual such as: n. Taking care of physical health issues; n. Taking care of mental health issues; and n. Reconnecting with non using family/friends. It is important to relate all tasks and goals back to how it is affecting the member’s addiction.
Treatment Plans and Discharge Plans (cont. ) n Client is 40 year old female; n Involuntarily committed; n Co-occurring; n Was taking a medication but doesn’t remember the name; n Previously diagnosed with major depression; and n States that she drinks as a way to manage the depression.
Treatment Plans and Discharge Plans (cont. ) n What would the treatment plan goals be? n If the client made it though the program, what would the discharge plan look like?
Case Study Review case study and identify potential errors.
SRS Regulations n R 03 -603 – Client Case Records n R 03 -604 – Progress Notes n R 03 -605 – Assessment n R 03 -606 – Treatment Planning & Updates n R 03 -608 – Discharge Documentation
References n http: //www. access. gpo. gov/nara/cfr/waisidx_03/42 cfr 455_03. html 42 CFR Part 455 n http: //www. access. gpo. gov/nara/cfr/waisidx_02/42 cfr 456_02. html 42 CFR Part 456 n http: //ecfr. gpoaccess. gov/cgi/t/text- idx? c=ecfr&rgn=div 6&view=text&node=42: 4. 0. 1. 1. 2. 2 &idno=42 42 CFR Subpart B § 431. 54(e) n http: //www. oig. hhs. gov/authorities/docs/exclusion 918 98. pdf 42 CFR Part 1001& 1002
References n http: //www. cms. hhs. gov/Deficit. Reduction. Act/Downloa ds/CMIP%20 Initial%20 July%202006. pdf Medicaid Integrity Group n http: //www. hcpro. com/publication-enewsletter-862 - department-corporate-compliance. html Compliance Monitor Newsletter n http: //www. ct. gov/ag/cwp/view. asp? Q=453916&A=38 69 First HITECH lawsuit n http: //www. ksag. org/page/medicaid-fraud-and-abuse- unit Kansas Medicaid Fraud and Abuse Unit