How would a clinician bill for meeting with the family for the purpose of re-assessing the case for the annual or 6 month review and go over progress in tx goals and to develop or update the CSP?
The most appropriate way to bill for this service is "Assessment" (CPT 90899-6). Make sure that the note reflects the above question by providing a brief update of the case, its progress, barriers to treatment, changes in the frequency or modality being used, etc. Also, please remember that assessment notes include the following elements: that the sole purpose of the meeting was for gathering information, feedback and client participation on the CSP. Reminder: Assessment notes do not need a clinical intervention, but should document a plan.
If a clinician meets with a family for the purpose mentioned in the above scenario…but also meets for the purpose of doing collateral therapy to address an issue in regards to the client in attempts of ameliorating that issue/problem then what is the best way to bill for this session?
The best way to document for these services is to have two separate EDs/PNs; an "assessment" for the first part of the session and then “collateral” with or without client for the second part of the session. Both of these services can be dropped on the same day.
How would a clinician figure out the Annual Update Timelines?
Medi-Cal requires the assessment paperwork be updated on a yearly basis, including a mental status exam. In order to do this, clinicians must be aware of the Medi-Cal month of intake, which is usually the month when the case was opened for services within a CYS/contract agency. The Annual Update is always due by the first day of the Medi-Cal month of intake. For example, if the case was opened on July 25, 2008, the Annual Update will be due by July 1, 2009. Please be aware that it is the clinician's responsibility to determine that the case is not already open at another clinic. Check the IRIS Coordination of Care report to determine the current Medi-Cal timeline. If the case if already open at another clinic, the clinician must follow the existing timeline. This also applies to those situations where the case was recently discharged from another clinic. A new Medi-Cal timeline cannot be started unless the case has been closed for 90 days or longer.
What information should be included in an assessment progress note?
The assessment progress note must include a statement about the reason for the assessment that day and at least one of the following elements:
gathering history of presenting problem
performing a mental status exam
obtaining information about relevant cultural variables
obtaining information to clarify the diagnosis
Basically it is only a collection of information that will be helpful for the clinician in their development of their diagnosis. In that sense, you do not need a clinical intervention, but rather a plan. This is what makes the assessment note different from a case mgmt note or treatment note.
Can a one time assessment with a conclusion that client has an excluded diagnosis be billed to Medi-Cal?
Yes, a one time assessment with a conclusion that a client has an excluded diagnosis can be billed to Medi-Cal. Remember to complete a Notice of Action (NOA-A), give a copy to the consumer/caregiver immediately, and document this in the progress note. Subsequent sessions cannot be billed to Medi-Cal after a consumer has been diagnosed with an excluded diagnosis. Make sure it is an assessment code and not billed as crisis code. In order to bill crisis intervention, the consumer must have a Medi-Cal included diagnosis. We cannot bill crisis with an excluded diagnosis, not even for one service.
Is it a billable service if a clinician is reviewing previous assessment paperwork during their own assessment period?
Reviewing a previous assessment or other documentation is a billable service to Medi-Cal. It is expected that the progress note documenting the review will provide a summary of the information reviewed, and how this information will be used as part of the assessment process. Also, please be aware that the progress note should clearly support the amount of time billed for this service, and must specify where the reviewed documents are located in the chart. For example: a psychologist bills for reviewing prior psychological testing. The progress note should document a summary of the previous findings, how this information will be used in the current assessment, and in what section of the chart a copy of such psychological testing report can be found.
If the assessment paperwork is completed and billed as assessment but the minor was not available to sign……how is the next meeting billed if the majority of the session is an individual and the CSP was reviewed with the client during this session?
There are two ways to approach this situation. First, if the great majority of the session was spent on doing individual treatment, then bill the session as individual therapy even though the documentation could include a line or two indicating that the CSP was reviewed and approved by the consumer. Second, the clinician can decide to do two notes, billing one as assessment for the time it took to review and approve the CSP and the other for the time of the individual therapy. For example: if it took a half an hour to complete the CSP and a half hour was focused on the individual session, then two notes are needed.
At the end of the assessment period (30 or 60th day*) all paperwork (Assessment Summary, Mental Status Examination, Master Treatment Plan and Client Service Plan) must be completed with all necessary signatures. In addition, there should be a brief stand alone assessment note showing the client's participation in the development of the CSP and agreement to the treatment goals, which is noted by the client’s signature. Medi-Cal will accept the consumer/legal guardian not being available for signature, only in extraordinary circumstances (i.e. death of a family member, natural disaster, client hospitalized, etc.), which should be clearly documented in the chart. Remember that the expectation is that the consumer/legal guardian signature will be obtained at the next session.
The Assessment Summary and CSP must be completed within 60 days from admission date if the consumer is not opened in any other CYS program. However, if the consumer is opened in another CYS program OR if it has been closed from another county or contract program less than 90 days from your admission date the Assessment Summary and CSP must be completed within 30 days from the initial admission date and you must adopt the holder’s Medi-cal month of intake timelines.
Can services be billed if a client is on AWOL status?
Clinicians cannot bill for any services when a child AWOLS/runs from CEGU, placement or home. If services are provided during the above situations they are to be provided with non-billable codes.
Clinician goes to a school but child does not show for treatment, but clinician phones guardian and discusses case and the situation how should this be billed?
The clinician should drop two separate EDs/PNs; one as a non-billable CM, including the travel time, documenting they went to the school and that the client was not there. The second note would be a billable over the phone (collateral) service for speaking to the guardian as long as the clinician provides a clinical intervention.
Rescheduling of an appointment is not billable.
If a case is transferred from one CYS program to another program, could the new clinician just sign on to the previous paperwork (Assessment, MTP, and CSP)?
Immediately following are two paperwork options to consider when a case has been transferred. The first option is preferred because the new clinician conducts their own assessment and develops a new MTP and CSP. The second option puts the new program at risk if a comprehensive review of the entire paperwork was not completed by the new clinician. For example: paperwork has been recouped because the previous paperwork was done incorrectly with no evidence of Medical Necessity or the CSP was done incorrectly with expired milestones.
Option 1: The new program has to do the entire paperwork (assessment summary, MTP and CSP) and continue with same timelines (within 30 days of transfer).
Option 2: The new program gets a copy of the paperwork from the other program (or gets the entire chart if this is a transfer from another county clinic) and just adds themselves onto the MTP; co-signs the MTP and the CSP. Adding the signature to the existing MTP and CSP means that they have reviewed and agreed with this paperwork. They continue to follow up with the same timelines.
So, in other words, option one and two are acceptable, however, number one is the ideal to avoid any problems later in a review.
Good clinical practice would be that if the new clinician signs onto the previous paperwork then they should complete a mental status exam and drop a note saying they have "reviewed and accepted the assessment and CSP from the previous program and will continue to work on the goals and milestones listed on the CSP". If any changes are made to the CSP goals, a corresponding progress note should be completed noting that the CSP was updated. In addition, have the client sign the CSP update.
Can Clinician’s bill for writing a Child Abuse Report?
No. Medi-cal considers the completion of a Child Abuse Report as clerical duties. Calling to make the report is billable, but not the writing of it even though the report is written by a clinician. Time to complete the report can be claimed as a non-billable service.
What are the current 24-hour claiming limitations listed by service type?
The maximum amount billable for Crisis Intervention in a 24-hour period is 8 hours or 480 min. This includes the total time of several clinicians or even other agencies.
The maximum amount billable for Medication Support Services in a 24-hour period is 4 hours.
Can staff bill Medi-Cal for photocopying, faxing, and other clerical type activities?
No, these services are not considered part of specialty mental health services.
Can services be billed that are not on the CSP but are on the MTP? What if a service is being billed that is neither on the MTP or CSP?
The specific type of service must be on the MTP and CSP in order to bill for that service. If a service is provided and the service is not listed on both documents, then it must be coded as a noncompliant chart code. Once such service has been added to the MTP/CSP, then the following services can be entered as billable services.
Also, in regards to adding anything to the CSP, after it has been signed by all of the required parties, whatever the addition is, it must be dated and there must be a progress note reflecting the type of service which was added. Please be aware that if significant or too many changes need to be made to a CSP, it is better to create a new, updated one. All required signatures are needed for the updated CSP. Making changes to the CSP after it has been signed can be seen as fraudulent by Auditors.
Are clinicians able to bill MediCal for services they provide on a county holiday?
Yes they can, if they were scheduled to worked that day. The amount of time billed on that day should never exceed the amount of hours that the clinician was scheduled to work according to their timesheet.
Can telephone calls be billed as crisis intervention?
Crisis intervention can be provided in person or on the telephone anywhere in the community. Crisis intervention must follow strict documentation requirements, and always refers to the consumer's crisis. It cannot be about the crisis of the parent or guardian. Critical elements of a crisis intervention progress note are the following:
Typically involves an unplanned event, i.e. unscheduled session, but it can also occur during a regular session.
Documentation should reflect the seriousness of the situation that merited it being a crisis
The clinician is expected to clearly document that a risk assessment was done, i.e. the consumer was assessed for suicidal or homicidal ideation.
The type of interventions that were employed to resolve or ameliorate the crisis
5 Axis Diagnosis
The type of disposition or recommendations for follow up care, i.e. involuntary hospitalization, psychiatric evaluation, increase frequency of services, etc.
If two clinicians traveled together to conduct a crisis evaluation could each clinician bill for the entire travel time or does each clinician only bill half the travel time?
Yes, each can claim the entire travel time.
How would you handle this situation, if two clinicians consult and note that they agreed with changed diagnosis, but the MTP is not updated?
The case coordinator/primary therapist is responsible for the accuracy of the MTP, and must immediately update the MTP by changing the diagnosis and checking the update box. If not part of the original consultation between the two clinicians, a progress note must explain the reasons for the change of diagnosis. In addition, the case coordinator/primary therapist should review the CSP goals to determine if they are compatible with the updated diagnosis. Otherwise, an updated CSP should also be developed.
What information is necessary for group documentation?
Group notes must be written in SIROP format. If two clinicians co-lead a group session, then two separate interventions need to be documented on the note. Both signatures are required on the progress note. There must be clear documentation in the note justifying the use of two group therapists and that there is a large enough group to justify billing for two therapists.
In addition to the general information required on the ED, please remember to include the total # of clients (Medi-cal and non-Medi-cal) in the group, number of staff and co-therapist name. The ED requires only the signature of the provider completing the ED.
Can staff bill Medi-Cal for a parenting group that includes parents whose children have open cases at the clinic?
Yes, if the services are directed at the mental health needs of the children, rather than based upon the needs of the parents. In addition, there must be documentation in the child's chart to show the need for this activity. Groups must be listed on the CSP.
When a treatment group contains both Medi-Cal and non Medi-Cal clients, how is staff to divide the time? For example, if a group of six clients containing three Medi-Cal and three non Medi-Cal clients lasts 120 minutes (group time plus documentation), how is the time divided? By three or by six?
The time must be divided equally among all six clients.
How would a clinician bill for services (i.e. case consultation, review of records, completion of assessment paperwork, etc) while a client is placed in a psychiatric hospital?
All services provided while the client is in the hospital with the exception of discharge planning are non-billable. With the exception, 30 calendar days immediately prior to the day of discharge for a maximum of three non-consecutive periods of 30 calendar days or less per continuous stay in the facility immediately prior to discharge for the purpose of placement.
Does the same rule regarding non-billable apply when client is in the hospital for medical reasons? For example, we get called out to complete a crisis intervention on a consumer who is hospitalized on a pediatric unit.
No, it is not the same. If the child is hospitalized for medical reasons, then Medi-Cal can be billed for providing mental health services. It is expected that the documentation in the chart would clearly indicated the medical reasons why the child is hospitalized. Make sure the clinician checks on the ED "Other Community Location" and not "Inpatient Medical".
What CPT code should an MD use when they assess a client over the phone for a refill?
Since this was a telephone based service the med support code to be used is 90899-8. The reason is that the other code (90862) requires a face-to-face service. In the insurance world outside of the county no telephone services are billable at this time. MD's may be choosing the case management code for the reason that they think that there is no legitimately billable med services code. They are right for the most part. But the reason we created the 90899-8 code is because in the insurance world of the county a non face-to-face service is billable as a medical service. We had to create a code that does not exist in the insurance world outside of the county in order to bill for that type of non face-to-face service. The 90889-8 code is okay.
An MD consults with a clinician medication issues. What CPT code should be used?
This should be a med service (90899-8). I would expect that the documentation would be about how the minor is doing and it could be an exchange of information between the MD and the therapist about the minor's response to medication or changes in medication, or the need for changes because of problem behaviors or the MD is asking the therapist for information about what the therapist sees in the minor’s behavior before and/or after medication changes, etc.
What code does a Nurse Practitioner use for a med evaluation?
The NP can use any of the codes the MDs use. For example the codes 90899-6, 90899-8 can be used. Of course the 90862 or the 90862-1 can also be used. There is really no difference between those two and so it is not necessary to use 90862-1 for an initial evaluation.
The NP should use the MD ED. The 90862 is appropriate for the NP to use also.
When an MD reviews lab results, what code is used?
It is suggested that Medication Services Codes could also be used. For example the MD could use a blank progress note and use the PIP format. For example:
Problem: Minor needs laboratory tests to meet goal of CSP for medication management services. (For instance minor needs lab tests to assure health status or monitor safety while taking medication etc.)
Intervention: Lab tests ordered and/or received.
Plan: Continue or change medications services based on results of the lab tests.
In our system the code could be 90899-8 if the minor is not present.
Otherwise if the labs review is part of the regular face-to-face appointment, then any of the codes for that type of an appointment could be used and the lab information can be put onto the Med Record form and follow that template. There is already a place on the Med Record to indicate the results of lab tests.
Can an MD bill for seeing and prescribing medication prior to the court giving authorization? I saw several today where the MD saw the client a few times then they completed the form to the court and it was approved several weeks later.
There is not a problem. A billable medication support note is not only tied to prescribing medication. It just has to be a legitimate medical service provided by an MD or a nurse. The services could be as simple as the MD evaluating the status of a minor in preparation for making a diagnosis or gathering information about whether medical treatment is appropriate or any factors that might effect the decision to provide medical treatment. It could even be the MD documenting that medical treatment is indicated but is being held up while waiting for court approval etc. If the minor is a dependent, there may already be a court consent that the MD knows about, even if that is not in the chart. If the already existing consent covers the medications the MD is prescribing then that covers what the MD is doing. It is also possible to start medication if the MD has checked the emergency box on the court consent form, even though the court has not given formal approval.
An MD used case management (Comp Med Svc Pharm Mgmt<20) to fill a prescription for a client who could not make their appt but was assessed briefly over the phone?
The case management code is OK but there is another option. Since this was a telephone based service the med support code that I would have used is 90899-8. The reason is that the other code (I think you are referring to the M0064 code or maybe the 90862 code) requires a face-to face service. I also should point out that M0064 can only be used for Medicare clients and only if the situation fits.
In the insurance world outside of the county no telephone services are billable at this time. MDs may be choosing the case management code for the reason that they think that there is no legitimately billable med services code. They are right for the most part. But the reason we created the 90899-8 code is because in the insurance world of the county a non face-to-face service is billable as a medical service. We had to create a code that does not exist in the insurance world outside of the county in order to bill for that type of non face-to-face service.
Do unlicensed clinicians who are waivered need to check the box on the ED under modifiers (LCSW, PhD)?
No. Only the LCSW and licensed PhD need to check these modifiers.
What are non-billable services?
These are services that clinicians provide to their consumers but Medi-cal does not reimburse for. These are generally appropriate services and should be documented in the client's chart as a Note to Chart or as a non-billable service.
All of the following are reminders of non-billable services:
Missed or scheduling appointments
Clerical activities – such as A.B. reports that are copied, residential packets that are faxed, or other activities that office support could complete.
Any services only addressing academic education, vocational service (work/training as its purpose), recreation or socialization that does not address the consumer’s mental health issues and impairments. In addition, tutoring, doing homework, employment searches, downloading information off the internet, etc…. are non-billable services.
Completion of discharge summaries is coded non-billable if not completed face to face with the client.
Filling out a Child Abuse Report is also considered a non-billable service following a verbal report to CAR.
Juvenile Hall – once a consumer is arrested and placed in Juvenile Hall all services are coded non-billable.
AWOLs - runaways from home/group homes, placement, juvenile hall, etc. are all considered non-billable services even if you are providing support to the parents or discussing plans for when the consumer returns.
Supervision – is a non-billable service if the supervisor is only monitoring client care.
Translation/interpretation – if the clinician’s only role is translator
Travel time between two certified Medi-cal sites is non-billable.
Travel time could have been a billable service but the client doesn’t show up, this is also a non-billable service.
Psychiatric Hospitalization - services provided to a consumer while they are hospitalized are considered non-billable services. However, discharge planning is a billable service if it applies to the following criteria: discharge planning may be billable within the last 30 days of hospitalization. The progress note must state, "Discharge Planning" and be written as a SIP note. The note must include: direct contact with hospital staff, arranging for out of home placement (not returning to the same placement/group home); and if applicable, consultation with receiving agency staff concerning transition to consumer’s new placement. Please be aware that scheduling aftercare appointments, collateral support services and consultation with own staff or updating SSA social worker are not billable under discharge planning.
* Excluded Diagnosis is non-billable as the primary diagnosis (i.e. Autism, Cognitive Disorder NOS, Substance Abuse, Medical Conditions that contribute to a mental health condition, etc.) for all mental health services.
Why would a note that is written as follows: proofread, edited and printed out a report be considered non-billable?
The way the note is written suggests a clerical function. The clinician needs to be more explicit in term of what she did for the service to be Medi-Cal billable. For example, If the note documented
The addition of new information gathered from client into the report, and explained how the CSP was updated based on the new information it would represent a service billable to Medi-Cal.
What actions take place when a child is denied services during or at completion of the evaluation?
A Notice of Action (NOA-A) is given to the consumer/caretaker immediately following the denial (due to the consumer having an excluded diagnosis, no impairment or condition is secondary to physical illness). Also, remember to document clinical services that were provided and results of the assessment and that an NOA-A was completed and given to the consumer/caretaker. Remember to complete the NOA-A section of the blue contact/access form (a new procedure that took effect 4/09).
Does psychological testing have to be listed on the CSP if it is completed after the initial assessment period?
No it does not, because it is a time limited service.
Could case managers bill for reviews of documents sent from RTC’s?
Yes, as long as the note has the necessary requirements (documents medical necessity, has a clinical intervention, and plan) then these can be billed as case management services.
Are TBS services added to the MTP under type of services? Or can it just be listed under outside of CYS?
They should be listed on the MTP under type of services and listed as 'TBS'. The name of the coach is the contact person. If the case is outsourced the coach’s agency should also be listed. The ‘from’ date is the date of the first TBS billing. It is recommended going to the end of the MediCal year for the ‘to’ date, since sometimes consumers have 2 episodes of care in a year. Just a reminder, Case Management should be on the MTP already when a coach is assigned to a case so that all providers can coordinate a consumer’s care.
Can a clinician bill for “completing TBS application and providing application materials to TBS office” as part of a case management note in which referral to TBS is being completed?
Yes, this is a billable service because it requires a clinician's clinical expertise.
If a client turns 16 years old during a CSP, when does the transitional goal have to be added?
Any transitional goals can be added/updated at the 6 month or annual review.
When would a clinician check the “Trauma” box on the ED’s?”
Clinicians are expected to check the "trauma" box whenever the client reports that he/or she has experienced it. It is a reminder for clinicians to assess for trauma because traditionally in our system it has been an under reported issue. A diagnosis of PTSD, victim of abuse, etc. is not required for the clinicians to check the box. Based on the client's history, a clinician should check trauma even though the client denies a traumatic event.
Can clinicians bill Medi-Cal for travel time from one provider site to another provider site? How about from a staff person’s residence to a provider site? Or from a staff’s home to a client’s home?
To bill Medi-Cal, travel time must be from a provider site to an off-site location(s) where Medi-Cal specialty mental health services are delivered. Therefore, Medi-Cal cannot be billed for travel time between provider sites or from a staff member’s residence to a provider site. Just a reminder, if a clinician travels to and from a Medi-Cal sitethen a Non-Billable Travel time code could be used.
Example: A clinician travels from Medi-cal site A to Medi-cal site B to provide a group therapy service. Travel time to any certified Medi-Cal site is to be coded as non-billable travel time. In this situation, you would need to put the non-billable travel time in the box with the correct CPT code for non-billable travel and not in the above box next to the documentation time where you usually put billable travel time.