Department of Medical Assistance Services

Department of Medical Assistance Services Residential TreatmentFor Children & AdolescentsLevel C (RTC) September & October 2010 www.dmas.virginia.gov

Residential TreatmentLevel C DMAS Contacts • William O’Bier - 804-225-4223 william.obier@dmas.virginia.gov • Pat Smith - 804-225-2412 for KePRO related questions patty.smith@dmas.virginia.gov • Tracy Wilcox-804-371-2648 Contract Monitor for Clifton Gunderson Audits tracy.wilcox@dmas.virginia.gov

Training Objectives: • Identify participation requirements • Understand Medicaid documentation requirements • Be aware of Service Authorization (SA) requirements and process

Objectives cont: • These slides contain only highlights of the Virginia Medicaid Psychiatric Services Manual (PSM) and are not meant to substitute for the comprehensive information available in the manual. • Please refer to the manual, available on the DMAS website, for in-depth information on psychiatric residential treatment criteria.

Provider EnrollmentUnit • For enrollment, agreements, change of address, and enrollment questions contact: Provider Enrollment Unit P.O. Box 26803 Richmond, VA 23261 • Toll free -- 888-829-5373 • Fax -- 804-270-7027

Provider Agreements • A Restraint & Seclusion (R&S) attestation letter must be submitted to DMAS by July 1 each year or sooner if change in CEO • Sample R&S attestation letter in manual

General Medicaid Provider Participation Requirements • Have administrative and financial management capacity to meet federal and state requirements • Have ability to maintain business and professional documentation • Adhere to conditions outlined in the provider agreements • Notify DMAS of any change in original information submitted and

Participation Requirements • Maintain records that fully document health care provided • Retain records for a period of at least 5 years • Furnish access to records and facilities in the form and manner requested • Use Medicaid designated billing forms • Accept as payment in full the amount reimbursed by DMAS. Provider must be participating in the Medicaid Program at the time the service is performed and

Participation Requirements • A provider may not bill a client for a covered service regardless of whether or not the provider received payment from the state • Should not attempt to collect from the client or family member any amount that exceeds the Medicaid allowance or for missed appointments • Hold all recipient information confidential • Be fully compliant with state and federal HIPAA confidentiality, use and disclosure requirements

Definition-Level C RTF • Program for children under age 21 to treat severe mental, emotional and behavioral disorders • When outpatient and day treatment fails • Provides inpatient psychiatric treatment • 24-hours per day program • Child-specific care and treatment planning and

Definition-Level C RTF • Highly organized and intensive services • Planned therapeutic interventions • All services required to be provided on-site, including academic program • Physician-directed mental health treatment

Restraint & Seclusion • Remain in compliance with signed agreement regarding seclusion and restraint • In case of injury requiring medical attention off-site or a suicide attempt, DMAS must be notified by fax within one business day of occurrence: • child’s name, Medicaid number • facility name & address of incident • location & date of incident and

Restraint & Seclusion Cont’d • Notification continued • names of staff involved • description of incident • outcome, including persons notified • current location of child • Fax to William O’Bier at 804-612-0059 • Restraint & Seclusion reporting is a condition of participation and non-reporting subject to retraction for paid claims and of provider enrollment

Out-of-State Facility Enrollment • Border-state facility (within 50 miles) • Provides a service not available in Virginia; or • No in-state facility willing to admit a specific child Procedure: • Contact DMAS at 804/225-4223 to discuss child-specific, out-of-state placement need • DMAS can enroll facility for single placement, if appropriate and

Out-of-State Placement Criteria • Requires prior authorization for Medicaid coverage • Recipient specific information required to be sent to DMAS: • Demographics • Referral source information • Current placement and services and why these are not adequate • Current documentation on diagnosis, behaviors, discharge plan • Current psychological evaluation -within past year and

Out-of-State Placement Criteria • Social and Service History pertinent to placement needs • Out-of-state facility information-website, documentation • List of Virginia facilities explored, and reasons for admission denial This will be reviewed by DMAS staff to assess the appropriate level of care and facility placement, and who will coordinate with provider enrollment if out-of state placement is approved

Electronic Submission of Claims • Claims should be submitted electronically • For CSA cases, when submitting SA information to KePRO, the 3-digit locality code and the Reimbursement Rate Certification rate are required. This will facilitate electronic submission of claims For NON-CSA cases, reimbursement will be at the rate established at enrollment. • All providers are expected to have a rate established at enrollment

Electronic Signatures • Clarification on electronic signatures issued in the 8-20-04 Medicaid Memo http://www.dmas.virginia.gov/downloads/pdfs/mm-use_electronic_signatures.pdf • An electronic signature that meets the following criteria is acceptable for clinical documentation: • Identifies the individual signing by name and title; and

Electronic Signatures • Data system assures the documentation cannot be altered after signature affixed, by limiting access to code or key sequence; • Provides for non-repudiation; that is, strong and substantial evidence that will make it difficult for the signer to claim the electronic representation is not valid; and • The provider must have written policies and procedures in effect regarding use of electronic signatures.

Required Documentation • The following slides describe the required documents for admission • All documents must be complete, timely and include all required dated signatures • Sample forms are available in the manual

Reimbursement Rate Certification For CSA Cases Only • Negotiated rate between locality and facility • Total rate can be no more than the Medicaid maximum • Payment from any other source such as Title IV-E, must be deducted prior to establishing the rate and

Reimbursement Rate Certification continued • Identify responsible locality • Locality code must be sent in for PA • If rate is revised by the locality, must be sent in to KePRO within 1 week to update the PA • Payment based on the rate on the certification which is entered by KePRO into the MMIS • All versions of the rate certification must be available at the facility for review

CSA or NON-CSA? • If the case is an Adoption Subsidy case, it is NON-CSA • The education payment source is not considered • If the education is paid for by the Dept. of Education/CSA funded, it is a CSA case • If a child has been receiving CSA funding for other services, it is a CSA case • If the child is in foster care, it is a CSA case

Certification of Need • CSA Cases • CON must be completed by both the physician and the FAPT • Must include dated signatures of physician and at least 3 members of the FAPT • Authorization can begin no earlier than the date of the latest signature • Must be child-specific and relate to the need for RTF level of care • Must be available in the medical record

Certification of Need(Independent Team Certification) • NON-CSA Cases • The CSB is responsible for completing the Independent Team Certification • The CSB completes the DMH224 and must include a physician’s dated signature, as well as the screener’s dated signature • The CSB may use the sample CON in the manual in place of the DMH224 and

Certification of Need • NON-CSA Cases • CON may be completed by the FAPT and must include a physician’s dated signature, as well as a member of the FAPT Authorization can begin no earlier than the date of the latest signature • Must be child-specific and relate to the need for RTF level of care • Must be available in the medical record

Certification of Need CSA and NON-CSA • Should reflect the child’s current condition and must be completed within 30 days of admission • Is required to be completed prior to admission with all necessary dated signatures • If discharged and readmitted, a new CON is required • If the child transfers to an acute psychiatric facility, the acute care team can do the new CON

State Uniform Assessment Instrument The CANS is the only uniform assessment instrument that is accepted

State UAI • CSA Cases Only • Must be current. For admission the state UAI should reflect the requested level of care • To be completed at least every 90 days and must be in the medical record • Should be updated by the fiscally responsible locality when the child’s level of impairment changes significantly • Completion information must be submitted to KePRO for SA and

State UAI • Scoring notes the level of impairment that supports the need for the level of care At a minimum: • The CANS summary sheet, indicating the child’s behavioral and emotional needs, and risk behaviors • The CANS must be available in the medical record and current within 90 days throughout the stay

Initial Plan of Care • Must be completed within 24 hours of admission • Requires a dated physician’s signature signifying the physician has had a face-to-face visit with the child (Authorization can begin no earlier than the date of the signature) • All required elements must be in the plan • See sample form in PSM-DMAS 371 • Be sure to specify the number and type of child-specific therapies • Must be in the medical record

Comprehensive Individual Plan of Care (CIPOC) • Must be completed within 14 days of admission • Must include dated signatures of the team responsible for the care (physician & at least one other team member specified in regulations) • Must include all required elements • See sample form in PSM-DMAS 372 • Be sure to include specific orders for therapies • Must be in the medical record

CIPOC 30-Day Progress Updates • Must be updated every 30 days • Must have dated signatures of team members • Must include all required elements • See sample form in PSM-DMAS 373 • List Individual and Family Therapy dates • If the therapy is not provided by a qualified professional, or the session was not at least 20 minutes, or there is no note, it should not be considered a delivered service • Address progress, or lack of progress. If no progress, how is this being addressed? 34

Therapeutic Interventions Individual, Family and Group Psychotherapy must be physician-ordered, provided by a licensed Medicaid enrolled provider and addressed in the treatment plan • Individual Psychotherapy • Must occur 3 times every 7 days. Facility determines the 7-day count. • Sessions must be, at a minimum, 20 minutes • If the session includes more than the therapist and the patient it is not considered individual psychotherapy • Telephone calls to family members are not considered individual psychotherapy and 35

Therapeutic Interventions Cont’d • Family Psychotherapy • Must occur at a minimum of 2 times a month if there is family involvement • If there is family dysfunction that impacts the child, therapy should be at least once a week. • Must be provided as is ordered in the treatment plan • Group Psychotherapy • Group Psychotherapy billed to Medicaid must not consist of more than 10 patients and

Therapeutic Interventions Individual, Family and Group Psychotherapy notes must be completed by a qualified therapist • If therapy is provided by an individual who has completed his or her graduate degree and is working towards licensure, they may do so under direct supervision SUPERVISOR • Appropriately licensed under state law and is a Medicaid-enrolled provider • Supervision meets requirements of individual profession and 37

Supervision of Unlicensed Therapists • Does not need to be the same person who is supervising for licensing purposes • Reviews patient’s medical history • Approves and signs Plan of Care indicating the need for the specific service • Countersigns Plan of Care updates • Reviews each therapy note • Must be in the facility during the session, but not required to be in the session and

Supervision of Unlicensed Therapists • Dated signature on each therapy note on date of service indicating note was reviewed • Meet regularly with supervisee (every sixth session or every 90 days, whichever comes first, to include all types of therapies ) • Discuss Plan of Care • Review record • Assess patient’s progress • Document supervisory meetings • A Physician’s Assistant, under supervision, is not eligible to provide psychotherapy 39

Therapeutic Interventions (including 21 weekly interventions) • Notes must contain, at a minimum: • Child’s name • Type of session (Individual, group, medication management) • If this is a group session, the type of group must be stated, such as Anger Management or Coping Skills • Treatment Modality • Start and stop time for session and

Therapeutic Interventions Cont’d • Pre-printed forms with date and time of session already printed is not acceptable • Written on the date service is provided • Activity of session-what therapeutic intervention/ interaction occurred, and how does it relate to goals • Purpose of note is to document service,and

Therapeutic Interventions Cont’d • as well as to assist staff in providing focused ongoing therapeutic services to the child • Level of participation (a check box is not sufficient) • Plan for next session • Dated signature of provider • All notes should be child-specific

21 Treatment Interventions Documentation • 21 Treatment Interventions every 7 days • May count group psychotherapy • Must not include individual and family therapy • Must be documented on a daily basis • Each intervention must be documented • Forms with check boxes as the majority of the note are not acceptable and

Documentation • Must document child-specific therapeutic intervention • Interventions that are not billable separately may include more than 10 residents (this does not include the group psychotherapy that may be billed separately) • Must include the dated signature of the provider for each intervention • This does not need to be licensed staff

Documentation Cont’d Late Entries--- • Timeliness of documentation is essential. A document is considered complete by review of the dated signature of the professional who develops the document. Back dating is not acceptable.

Restraint & Seclusion • Reports must be sent to DMAS reporting any injury requiring medical attention. These should be sent in within one business day of the occurrence. (See slide 9) • Restraint & Seclusion reporting is a condition of participation and non-reporting subject to retraction for paid claims and provider enrollment.

Staffing and Signatures • All signatures must be dated, and should include the professional title of the author • All medical documentation must include dated signatures on the date of service delivery • Auditors will request a staffing list with proof of licensure if license is required to provide a Medicaid reimbursed service

Service Authorization Contractor KePRO is the DMAS contractor for SA For questions go to the SA website: DMAS.KePRO.org and click on Virginia Medicaid Phone: 1-888-VAPAUTH or 1-888-827-2884 Fax: 1-877-OKBYFAX or 1-877-652-9329 Web:Provider Issues @ KePRO.org

Service Authorization Contractor Submitting a request • The preferred method is the iEXCHANGE® web-based program • Registration is required • Information on iEXCHANGE is available on the KePRO website, or call 1-888-827-2884 or by e-mail at providerissues@kepro.org

KePRO • Telephone to 888-827-2884 or 804-622-8900 (local) • Mail to KePRO 2810 North Parham Rd., Suite 305 Richmond, VA 23284

Service Authorization • Requests for SA are required to be submitted to KePRO prior to services being rendered, but no sooner than 10 days prior • Authorization can be for up to 90 days with medical justification • KePRO will review requests for medical necessity, as well as timeliness • KePRO will apply McKesson InterQual® Behavioral Health Criteria and DMAS supplemental criteria

Department of Medical Assistance Services