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Santa Barbara County Alcohol, Drug and Mental Health Services Medi-Cal Documentation Training June 2009 Update. WHY ???. Laws & Regulations Ethical Responsibility Best Clinical Practice Money

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Santa Barbara County Alcohol, Drug and Mental Health ServicesMedi-Cal Documentation TrainingJune 2009 Update


WHY ???

  • Laws & Regulations

  • Ethical Responsibility

  • Best Clinical Practice

  • Money

  • Accurate documentation is the legal and ethical obligation of everyone who provides mental health services.

The first law





  • All staff are responsible for helping assure

  • that services and documentation

  • comply with legal and ethical standards.

  • - ADMHS Code of Conduct


  • If you are aware of any possible compliance violations, you must report them immediately.

  • You may report to your Supervisor, Quality Assurance, or the Compliance Helpline.

  • phone: 681-5113 fax 681-5117

  • e-mail: [email protected]

  • Helpline (messages): 884-6855


  • Reports are confidential.

  • People who report are protected by State and Federal laws:

    Whistleblower Protections

    in the Federal False Claim Act:

    31 USC Section 3730 (h) protects employees against discharge, demotion, suspension, threats, harassment, or discrimination by the employer because of lawful acts done by the employee in cooperating with the False Claims Act, including investigation for, initiation of, testimony for, or assistance in an action filed or to be filed under this section.

Medi cal standards

Medi-Cal Standards

The basic medi cal rule

The Basic Medi-Cal Rule

  • Medi-Cal only pays for

  • mental health interventions.

  • Every progress note must say what you did and must be related to mental health.

  • Document all services – but without a mental health intervention, code it “No-Bill”

Medi cal vs whatever it takes

Medi-Cal vs. “Whatever It Takes”

  • MHSA was set up to pay for services not covered by Medi-Cal

  • So…

  • Not everything built into our MHSA programs can be billed to Medi-Cal.

Examples fsp locri

Examples: FSP & LOCRI

  • MHSA set up special forms that are required for some MHSA programs – ADMHS requires the LOCRI for adults in our clinics.

  • Unless something is added to those forms to make a billable service,

  • Filling out FSP & LOCRI = No-Bill service.

Excluded diagnoses can t be listed as primary

Excluded Diagnoses(can’t be listed as “Primary”)

  • Disorders due to a General Medical Condition

  • Substance-Related Disorders

  • Antisocial Personality Disorder

  • Cognitive Disorders (Delerium, Dementia, Amnesia)

  • Developmental Disorders

  • Autistic Disorder

  • Tic Disorders

  • Learning Disorders

  • Communication Disorders

How much time

How Much Time?

  • The time you claim must be the actual minutes spent delivering the service

  • Traveland documentationtime associated with a service can also be claimed

    • If you travel for more than 10 minutes, be sure to mention that in your note – don’t make the auditors guess!

Travel vs transportation

Travel vs. Transportation

  • Travel means going somewhere so you can provide a billable service. Whether or not a client goes with you doesn’t matter. Travel is billable.

  • Transportation means taking a client somewhere so somebody else can provide a service. Transportationis not billable.

Therapeutic behavioral services

Therapeutic Behavioral Services

  • This is a special service, only for consumers under 21, with full-scope Medi-Cal, who:

    • Have serious emotional problems and serious behavior problems caused by a mental disorder

    • Need special 1-to-1 short-term support.

  • If you think a child or young adult needs TBS, contact the consumer’s Care Coordinator or the Manager or Team Supervisor of the nearest ADMHS Children’s Clinic.

Client plans


Medi cal rule 2

Medi-Cal Rule #2

  • Medi-Cal only pays for interventions that are part of a written, authorized, signed Client Plan.

The client plan csp

The Client Plan / CSP

  • Legally required for all mental health providers.

  • Legally required to bill Medi-Cal or Medicare.

  • Provides informed consent for treatment.

  • Lets everyone know the goals of treatment and what services that will be provided.

Medi cal requirements

Medi-Cal Requirements

  • No services except Crisis Intervention and Assessment can be billed without a diagnosis and treatment plan.*

  • A complete, formal Client Plan must be developed and signed within 60 days after services start.*

  • The formal plan must be updated every year.


    * next page: what to do for 60 days!

But a formal plan takes time

But a formal plan takes time!

  • A Progress Note can authorize services for the first 60 days if it includes:

    • 5-Axis Diagnosis

    • Statement of Medical Necessity

    • Brief Description of Services

  • Clinician’s Gateway now has a template that meets all these requirements:

  • First Intake

Requirements formal client plan

Requirements: Formal Client Plan

  • The client or caregiver must participate in developing the plan.

  • The plan must be approved by

    • an LPHA or Psychiatrist* -and-

    • the client or legal guardian

    • Signatures on paper plans must include a DATE to be legal!

      * Medicare requires a psychiatrist

Adult client signature

Adult Client Signature

  • There is NO planuntil it’s approved by the Client or Guardian.

  • Adult clients must either sign a paper copy of the plan or decline to sign.

  • “Declines” means that the client was offered a chance to sign, in a face-to-face meeting, and decided not to sign.

  • “Declines to sign” is as good as a signature and is valid for 12 months.

Children s parent guardian signature

Children’s Parent/Guardian Signature

  • The parent or legal guardian can verbally participate in developing a plan and can verbally approve it.

  • The parent/guardian must sign (or refuse) the next time they are seen face-to-face.

  • Put the date of the verbal approval in the box for the parent/guardign signature.

Contents of the plan

Contents of the Plan

  • Goals – specific & observable & measurable

  • Proposed interventions to address the goals

  • Duration and frequency for interventions

  • Goals and interventions must be

  • consistent with the diagnosis



  • A goal is something that the client will achieve or acquire by participating in treatment.

  • There must be at least one goal for every impairment and every included diagnosis.

  • A goal must be something that can be observed and measured.

Measurable observable goals

Measurable / Observable Goals

  • Client will decrease angry outbursts to a maximum of 2 per weekas reported by family.

  • Client willreport no more than 1panic attack per week.

  • Client will increase compliance with authority by attending school 5 days/week.

  • Client will increase functioning by complying with prescribed medications every dayas reported by residential staff.

Common problem 1

Common Problem #1

  • Client will take medications as prescribed.

  • Problem: No connection to mental health – not the way it’s written.

  • Solution 1:Client will manage psychiatric symptoms by taking meds as prescribed.

  • Solution 2:Client will prevent increase in impairments by taking meds as prescribed.

Common problem 2

Common Problem #2

  • Client will not use alcohol or other drugs.

  • Problem: No connection to mental health

  • Solution 1:Client will decrease hallucinations by abstaining from alcohol or other drugs per self report.

  • Solution 2:Client will improve participation in rehabilitation by reducing alcohol use to no more than 3 beers per day per self report.

Common problem 3

Common Problem #3

  • Client will maintain residence in the community.

  • Problem: No connection to mental health

  • Solution 1:Client will maintain residence in the community as part of recovery.

  • Solution 2:Client will maintain residence in the community by continuing to manage symptoms.



  • An intervention is an action, activity, or service performed by another individual (usually a mental health provider).

  • A mental health intervention is an intervention related to a mental disorder.

Examples mental health interventions

Examples:Mental Health Interventions

  • provide therapy teach skills

  • evaluate symptoms

  • monitor progress help access services

  • educate family prescribe medications

  • gather information

  • review treatment plan

  • refer to physician


  • A Client Plan must have at least one mental health intervention for every goal.

  • Every intervention must have a frequency and duration – how often and for how long.

  • Basic examples:

    • Psychotherapy, 60 min per week, for 4 months

    • Med Support, 30 min per month, for 1 year

    • Individual Rehab, 30 min per day, for 6 weeks

New audit standard

New Audit Standard!

  • Every program that provides services must be listed in the Client Plan.

  • Every progress note billed to Medi-Cal must be related to the Client Plan.*

  • * Except emergencies, crises, decompensation

Progress note content

Progress Note Content

  • Must include:

    • The mental health intervention

    • A clear link to the client’s mental health condition or impairments

  • Should include:

    • Reason for the service

    • How the client looks and acts, and what the client says

    • Results of the service, or a plan

Progress notes do s

Progress Notes: “Do’s”

  • Write progress notes that stand on their own.

  • “Talked to Bob about client’s progress.”

    • You and your colleagues may know who “Bob” is – but other people don’t!

  • Write a progress note for every service activity, whether or not it is billable.

  • Write a progress note every time a client misses or cancels an appointment, and every time you miss or cancel.

Progress notes dont s

Progress Notes: Dont’s”

  • (1) Don’t just copy and paste notes.

    • You can follow a basic outline and use basic language – but identical notes will not pass an audit

  • (2) Notes must justify the amount of time claimed

    • “Sent fax to pharmacy” doesn’t justify 45 minutes. Write down what else you did!

  • (3) Don’t make personal comments or judgments in progress notes – words like ugly, stupid, repulsive, sexy, and gorgeous aren’t professional

Warning other client s names

Warning: Other Client’s Names

  • NEVER name other clients in any note – violates HIPAA.

  • NEVER name any person if you say something about that person’s health – mental or physical - whether they are a client or not.


Group Notes: Negative Example

  • Generic note: “New member Abel Ayala joined group today. Reviewed group rules. Demetrius Drake talked about his girlfriend being pregnant and group discussed pregnancy and parenting.”

  • When Bob’s medical records are released, confidential information about the other group members is also released – without their authorization.

  • Don’t name other clients in any note!

Individual notes negative example

Individual Notes: Negative Example

  • George’s mother Bernadette is taking medications to help with her anxiety. His brother Arnold is in treatment at Good Sam and is testing clean. His sister Edith, who he molested last year, is in treatment for PTSD.

  • That note includes Protected Health Information regarding 3 other people and gives information that identifies them. That is a serious violation of HIPAA.

Specific procedures

Specific Procedures

These services can be reimbursed by medi cal

These Services Can Be Reimbursed by Medi-Cal

  • Mental Health Services

    • Assessment

    • Evaluation and Plan Development

    • Therapy – Individual, Family, Group

    • Rehabilitation – Individual, Group

    • Collateral – Individual, Family, Group

  • Targeted Case Management

  • Crisis Intervention

  • Medication Support Services

  • Therapeutic Behavioral Services (TBS)

Procedures which can be provided by anyone regardless of license

Procedures which can be provided by anyone, regardless of license:

  • Evaluation and Plan Development

  • Collateral – Individual or Group

  • Rehab – Individual, Family, or Group

  • Targeted Case Management

  • Crisis Intervention

  • TBS – licensed or under licensed supervision

Eval plan development

Eval & Plan Development

  • EVAL: Gathering information about symptoms and functioning – only if it’s clearly related to PLAN DEVELOPMENT:

  • PLAN: Development or approval of plans, and monitoring client progress toward plan goals.

  • The formal, official Client Plan does not have to change – there can be changes in short-term interventions and activities.

A major medi cal no no

A Major Medi-Cal “No-No”

  • “Narrative, descriptive notes” cannot be claimed – they must be coded “No Bill”.

  • To use a service code that bills Medi-Cal, a note must describe a mental health intervention – something you did.

  • Some of us were taught to write exactly this kind of note – but Medi-Cal says “NO BILL”

Narrative descriptive notes

Narrative, Descriptive Notes

  • Example: Client neatly groomed, dressed in worn but clean suit. Movements, gait, posture stiff. Tangential speech at times. Denies hallucinations, delusions, SI, HI. Affect restricted, described mood as “worried” but unable to give details. Getting along with parents but he and brother still not speaking. RTC 1 week.

  • No intervention, code as “No Bill”

Team meetings

“Team” Meetings

  • The only people who can bill are people who are actively involved in providing treatment to the client.

  • The total amount of time billed can’t be more than 2 times the time the meeting lasted, plus documentation.

  • Each person who bills must document that they made an active intervention involving clinical decision-makingor clinical thought.

Example multi staff eval plan

Example: Multi-Staff Eval/Plan

  • Reviewed client plan with team. Client will continue med management, substance abuse treatment, case coordination and individual therapy with focus on trauma.

    • Staff 1:I stated that individual therapy is necessary for continued progress.

    • Staff 2:This writer asked questions about the client’s substance abuse and how it relates to her PTSD.

Multi staff eval plan

Multi-Staff Eval/Plan

  • Some words that show an active intervention:

    • Said

    • Suggested

    • Asked

    • Discussed

    • Questioned

    • Proposed

    • Talked about

Clinical supervision

“Clinical Supervision”

  • If it looks like clinical supevision, it is clinical supervision – and that is a “No-Bill” service.

  • Consulting, talking with, reviewing cases with a person who is not providing direct treatment services to that individual client is clinical supervision.

Clinical supervision example

Clinical Supervision - example

  • Reviewed case with Program Manager. Client is not responding well to therapeutic recreational activities. Will focus on art activities instead.

  • If the Program Manager is providing Assessment, Rehab, Therapy, or Collateral services to that client, this is Eval & Plan.

  • If the Program Manager isn’t providing direct treatment, this is TCM – No Bill.



  • Services provided:

  • to (or with) a significant support person in the client’s life.

  • to help the client improve or maintain mental health status & achieve goals

Collateral continued

Collateral - continued

  • Includes:

    • consulting, educating, or training the person about the client’s treatment, illness, progress, ways to help

    • gathering information about the client’s symptoms, treatment progress, or goals, which can be used in assessment and/or treatment planning

  • Documentation must say how the people are related to the client – father, friend, landlord, etc.

Odds ends collateral

Odds & Ends - Collateral

  • Helping the support person with their own mental health issues is not billable.

  • Example: Client’s mother very anxious. Taught deep breathing skills. She felt more calm. Code as “No Bill” – focus NOT on client.

  • But: Client’s mother very anxious. Discussed client behaviors which have increased her anxiety, suggested more effective ways to deal with his symptoms. She felt more calm.” Code as “Collateral” – focus is on client.

More collateral odds ends

More Collateral Odds & Ends

  • Collateral cannot be with another mental health provider.

    • “Mental health provider” is someone:

      • who has a mental health license, or

      • is paid by mental health Medi-Cal.

  • ADMHS or CBO staff, psychiatrists, staff at a psych hospital, etc. are “mental health providers.”

Working with another mental health provider

Working With “Another Mental Health Provider”

  • Exchanging information which helps the client access services on the Client Plan is Targeted Case Management.

  • Note: School psychologists are not “mental health providers.” Neither are physicians who are not psychiatrists – even if they prescribe “psychiatric” meds.



  • The key to Rehab is SKILLS

  • The purpose of Rehab is to improve, maintain, restore, develop, increase, teach, etc. skills.

  • Skills include daily living, thought-stopping, social & leisure, hygiene, self-soothing, cooking, meal planning, shopping, public transportation, relaxation, money management, skills to comply with meds, skills accessing and using services, etc THE SKILLS MUST ADDRESS IMPAIRMENTS IN THE LATEST ASSESSMENT, OR GOALS IN THE CURRENT CLIENT PLAN.

Example 1 rehab

Example 1: Rehab

  • “Client wants money to buy a mini fridge for her hotel room. She found one for $103.28 including tax. Arranged check.”

  • No skills, no mental health intervention.

  • “No Bill” service.

  • Billable:add “Reviewed & praised client’s use of comparison shopping skills which were previously discussed with her.”

Rehab not rehab

Rehab – Not Rehab

  • Rehab means helping clients do things for themselves – NOT doing things for them.

  • Examples:

  • Yes: Reviewed budgeting and shopping skills, went to store with client, reminded her to follow her list and not buy impulsively.

  • No:Went to store and bought food for client who was unable to go because of agoraphobia.

Rehab and medications

Rehab and Medications

  • No:Observed client taking prescribed meds.

  • No:Went to client’s apartment to deliver meds. Watched client take meds because client is not able to take meds regularly without monitoring.

  • Watching someone take meds is “No-Bill” - there is no mental health intervention.

Meds and rehab

Meds and Rehab

  • Helping a client develop-improve-maintain medication compliance skills is a valid (and valuable) Medi-Cal mental health service.

  • To bill for this activity, you need to document a clear set of activities in which can clearly help the client develop observable, measurable med compliance skills.

Example very basic med skills protocol

Example: Very Basic Med Skills Protocol

  • Where is your med cassette?

  • What day of the week is this?

  • Which meds are you supposed to take today?

  • Open it. Do you recognize those meds? Are they the meds you’re supposed to take now?

  • Do you need to take them with water? With food?

  • Let’s check the med bottle. What problems are you supposed to watch out for? Do you think you’ve had any of those?

  • Take your meds.

  • Put your med cassette away.

Med skills protocols

Med Skills Protocols

  • Every program that actually does rehab with med compliance skills should develop “protocols” (lists of steps) to fit their clients.

  • There must be different levels of protocols for clients with different levels of needs.

  • It must be possible for clients to move from one protocol to another as their needs change.

Words to avoid

Words to Avoid

  • Words have different meanings in

  • English and Medi-Cal – be careful!

  • Administered medications is a medical term. It means you gave the client an injection. Requires a medicl license.

  • Monitored medications is also a medical term. It means you did a medical check for side effects and med interactions, and did other things that require a medical license.

A special twist group rehab

A Special Twist: Group Rehab

  • Group rehab must include individual feedback to the individual client re: something specific.

  • Yes: Group used discussion and role playing to enhance social skills when shopping. Reminded Jose several times about not talking loudly or shouting.

  • No: Group discussion and role playing to enhance social skills when shopping. Jose had some problems but participated actively.

Not rehab code no bill

Not “Rehab” – Code “No Bill”

  • Home visit. Client’s room was clean and she had adequate food. No MH intervention.

  • Helped Chang maintain time management skills by reminding her of psychiatrist appointment. Appointment reminders are not billable.

  • This staff went to the park with the clients to enhance their skills in connecting with the natural world. Ted walked quietly and calmly under the trees and enjoyed the experience. No mental health intervention.

Rehab examples

Rehab Examples

  • Helped client improve dietary skills by helping her check food on hand and making a shopping list of things she needs to buy.

  • Home visit. Kitchen was dirty with food spilled on stove and counters. Reviewed & helped improve cleaning skills by modeling and feedback.

  • Helped client improve access to services by accompanying to Adult Ed art class, monitoring social and relaxation skills, and making suggestions.

More rehab examples

More Rehab Examples

  • Visited school. Monitored interpersonal skills in class and on playground. Reviewed times when Billy did and didn’t use anger management skills well.

  • Met with Mona and family, started teaching them anger management skills with “time-outs.”

  • Initial meeting with Yoshi. Played board games to build relationship and start to help him improve skills in focusing and cooperation with others.

Targeted case management

Targeted Case Management

  • Helping a client access needed services –

  • not providing the service. 

  • TCM may include communication, coordination, and referral; making sure services are being provided. 

  • TCM must be related to the beneficiary’s mental healthand part of the Client Plan

  • – otherwise, it’s a “No Bill” service.

Tcm examples

TCM Examples

  • No: Received, reviewed and placed into the ProPay chart a copy of the Trust Account balance.” No mental health intervention. Code this as “No Bill”

  • Yes: Helped client improve money management skills by going over bank statement and bills. Praised client for keeping bills in the “In” tray and keeping enough money in bank to pay them.

More tcm examples

More TCM Examples

  • NoFilled out Medi-Cal renewal forms for client. No mental health intervention – doing things for the client. Code this as “No Bill”

  • Stay tuned – the next slides are about when you can bill for helping clients with forms!

Filling out forms 1

Filling Out Forms #1

  • If you fill out forms, it’s a Clerical Function.

  • But… Cognitive impairments due to schizophrenia prevent client filling out forms accurately, so staff met with client and completed Medi-Cal application with the input client was able to provide.

  • The client is present & participates, staff has to help because of mental health impairments. Code as TCM.

Filling out forms 2

Filling Out Forms #2

  • Helped client learn skills in filling out forms in order to access needed services. Reviewed Medi-Cal re-auth form with client, explained wording and meaning of questions, helped client complete form accurately.

  • The client is present & participates, focus is on skills. If you really helped the client develop these skills, code as Individual Rehab.

Even more tcm examples

Even More TCM Examples

  • No: Went to Wal-Mart, bought small toys family can use as rewards for Angelina doing chores. No mental health intervention – doing things for the client’s family. Code as “No Bill”

  • Yes:Reviewed targeted behaviors with parents, when and how to use small toys as rewards.Could also be coded as Collateral.

Crisis intervention

Crisis Intervention

  • There must be an acute needfor services.

  • Ask yourself: “If I had not provided this intervention, would the client have been at imminent risk of danger to self or others?”

  • Does not have to end up with a 5150, but the situation has to be so acute that a 5150 might be possible.

Not crisis intervention

NOT Crisis Intervention

  • Client here without appointment saying she is in crisis. Reports "I'm doing much better since I started Zyprexa but I’m still having panic attacks." Appears anxious, speech well paced, denies significant depression or suicidal thoughts at present. Will keep appt next week.

  • The client says it’s a crisis – that doesn’t make it a crisis. No imminent threat.

Real crisis intervention

Real Crisis Intervention

  • “Client depressed, possibly suicidal. Did suicide assessment. Passive SI, no clear intent, no plan. Willing to contract no harm for 24 hours, will follow up tomorrow.”

  • “Client appeared agitated, angry. Shouting, many obscenities, hard to understand meaning. Stopped Risperdal about 2 weeks ago, hearing voices, thinks people are insulting him, wants to beat them up. Calmed client somewhat, picked up by CARES staff for followup.

Restricted procedure codes lpha

Restricted Procedure Codes: LPHA

  • Assessment

  • Family Therapy

  • Individual Therapy

  • Group Therapy

  • MD, PhD, LCSW, ASW, MFT, IMF, some RN, post-degree psych intern

Restricted procedure codes

Restricted Procedure Codes

  • See the training for Assessment –

  • Coming soon!

  • Follow the Rehabilitation guidelines for Therapy – except that a psychotherapeutic intervention that addresses targeted symptoms is required instead of a focus on skills.

Special problems


  • Writing reports

  • Transportation

  • Translating/Interpreting

  • If that’s all you did, it’s a

  • NO BILL service



  • Writing reports is a clerical function, therefore not a mental health service.

  • Writing reports for Social Security, Social Services, Probation, CWS, … are Targeted Case Management – No Bill.



  • Just transporting a client to or from a service is a “No Bill” service.

  • But…

  • If you provide a billable mental health service while transporting the client, the actual time spent on that intervention can be billed. Be sure to document the intervention fully, and only bill the time you did the intervention.

When transporting is really travel

When “Transporting” Is Really “Travel”

  • If:

  • The client’s mental health impairments significantly interfere with the ability to exchange important medical information with a provider–

  • and

  • you take the client to the appointment so you can bepresent with the client during the appointment in order to help the client communicate

  • that is covered by Medi-Cal as TCM.

Example transportation

Example: Transportation

  • No:Met client at home, transported him to med appointment. I observed that client’s dress and grooming are appropriate and that client interacted appropriately.

  • Yes: Met client at home, transported him to med appointment. I reviewed relaxation skills and role-played communicating with the doctor since he often has anxiety when seeing psychiatrist. Transport time not billed.

Reminder tell the truth

Reminder: Tell the Truth

  • Never use misleading wording to try to disguise the fact that you transported a client!

  • If you drive a client to an appointment, don’t bill your time and say you “assisted the client in accessing an appointment” or “facilitated client’s access to a service.”

  • Say that you transported the client and document as TCM – No Bill.

Public transportation

Public Transportation

  • Helping a client learn to use public transportation is Rehabilitation.

  • Example: Client unable to use public transport alone due to fears and confusion. Reviewed skills client could use, then took bus with client to SSI and back home. Client expressed some anxiety while on bus, staff gave feedback and support. Praised client for success using bus but continues to need assistance.

Translating interpreting

Translating - Interpreting

  • If you just change words from one language to another, it’s a “No Bill” service.

  • But… If you actively participate in providing a service, document that.

  • Met with doctor and family, provided interpretation. Helped client, parents, staff communicate. Explained cultural issues involved to doctor, family.

Restricted procedure codes medical

Restricted Procedure Codes: Medical

  • Medication (MD/DO only)

  • Medication Visit – Brief (MD/DO only)

  • Medication Administration

  • Medication Support

Special situations

Special Situations

No bill procedures

“No-bill” procedures

  • Targeted Case Management – Non-Bill

  • Client No Show

  • Client Cancelled

  • Staff Cancelled

  • Even though these do not produce income, they must be documented. These events are important aspects of the client’s treatment record.

Always code no bill

Always Code “No Bill”

  • Email or voice mail messages

  • Appointment reminders

  • Services while client is in Jail or Juvenile Hall

  • Tutoring or job training.

  • Personal care – doing cleaning, laundry, bathing, grooming, shopping for the client

Missed appointments

Missed Appointments

  • Missed appointments are “No Bill” services

  • Unless you provide a different service:

  • Collateral services – exchanging information with a support person.

  • Writing a letter to the client about what to do next, reminding the client about skills he/she has been taught, etc.

While the client is hospitalized

While the client is hospitalized

  • Document everything as “No Bill” except:

    • Targeted Case Management

    • for discharge or aftercare planning

Substance abuse

Substance Abuse

  • Services related to substance abuse are “No Bill” unlessthey have a clear focus on mental health issues:

    • Mental health symptoms

    • Mental health impairments

    • Mental health treatment

No bill substance abuse

“No Bill” Substance Abuse

  • “Client drinking heavily again. Probably needs detox. Citation for public intox. May be VOP, could go back to jail. Called Project Recovery but failed last 3 detox tries. Will talk with pgm mgr later re: what clt needs to do to get back in.”

  • “Met with client and group of other addicts. Discussed reasons they have used drugs and ways to stay clean and sober.”

  • Important services – Important information.

  • Code as TCM – No Bill.

Substance related and covered by mental health medi cal

Substance-Related and Covered by Mental Health Medi-Cal

  • “Client reports recent relapse with increased psychosis. Used after rejection by GF. Not taking Seroquel since relapse. Worked with client re: steps to take – will go into detox as soon as a bed is available, will see psychiatrist re: restarting meds ASAP.”

  • Eval & Plan Development

Closing cases

Closing Cases

  • Closing cases is only a mental health intervention when there is a clinical decision or intervention such as referral to another service or support system.

  • “Closed case,” “completed documentation required to close file,” etc. are clerical only and therefore “No Bill” services.

Case closing mental health intervention

Case ClosingMental Health Intervention

  • No: Closing case. No contact for 4 months.

  • No: Client no longer interested in services, so case closed.

  • Yes: Client no longer interested in services, so case closed. Explained to client how he can receive services in the future if he changes his mind.

Consumer concerns

Consumer Concerns

  • Consumer concerns, complaints, requests, etc. require documentation and resolution.

  • Consumer concerns can be resolved:

    • Through an informal, local, verbal process

    • Through a formal, written grievance

    • Through a formal state hearing process

Informal local resolution

Informal, Local Resolution

  • Client verbally notifies staff of a concern.

  • Staff resolve the client’s concern.

  • The client is asked if the resolution issatisfactory and the client says “yes.”

  • Each step must be documented.

Formal grievance process

Formal Grievance Process

  • A concern becomes a grievance and must be forwarded to QA whenever:

    • The consumer makes a written complaint.


    • The consumer is not satisfied with a local, informal resolution.

Formal grievance process1

Formal Grievance Process

  • QA contacts the consumer to clarify what the consumer wants to happen.

  • QA contacts the supervisor or manager (and usually other staff involved) to gather information.

  • QA determines whether or not any laws, regulations, or department policies were violated.

  • QA gives a written notification of the outcome to the consumer and the program.

  • The consumer may appealor request a state hearing.

Admhs timeliness standards

ADMHSTimeliness Standards

  • Progress notes must be entered in a timely manner:

    • Best practice iswithin 24 hours

    • Each program manager sets standards for their program.


Questions?Quality Assurance 681-5113 fax 681-5117Jeanie Sleigh [email protected] [email protected]

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