MD DOCUMENTATION TIPS

1. MD DOCUMENTATION TIPS Addendum to Basic Documentation Training

2. Medi-Cal and Medicare • These two agencies are our primary payers. They have very different documentation standards. • Medicare only pays for face-to-face services and related documentation. We document these services using service code 15. • Medi-Cal allows a broad range of billable services, including consultation, telephone calls, staff transportation, etc. For these services, we use service code 17.

3. Assessments • Use Service Code 15-medication support whenever a PIN and/or an admission assessment or annual assessment is completed. • The PIN may serve as the only admission assessment. • Documentation time on the day of the assessment, even when the client is no longer present, may be coded 15 and included in the time charged for the assessment. • Documentation of the assessment on another day should be coded 17.

4. Client Treatment Plans • Because medication management is usually a major part of the program’s goal/s and treatment intervention/s, MDs use Service Code 15-medication supoprt for their work with clients in developing the Client Treatment and Recovery Plan.

5. Activity Codes15 or 9? • Use Service Code 15-medication support when you meet face-to-face with a client and the primary service you provide is medication support. • Use Service Code 9- individual therapy when you meet with a client and the primary service you provide is therapy with medication support as incidental, for instance in most training therapy visits.

6. Telephone Calls When the MD calls the client: • Use Service Code 17 (non face-to-face) when the client or support person answers the phone and the discussion is about medication, symptoms, side effects, etc. • Use Service Code 55 (no charge) when the client answers the phone and the only discussion is about making an appointment for the next visit. • Use Service Code 55 (no charge) when the client or support person does not answer the phone and you leave a voice mail message. +Location Code Vmail.

7. Pharmacy Related Activities • Use 17 when calling a pharmacy about a client’s prescription. • Use 17 for completing PARs. • Use 17 when informing a family member or caretaker by telephone about medications. • Use 15 for face-to-face conversations with a parent about medications.

8. Completing Forms • Use service code 17 when completing disability forms, VRS referrals, etc. • Use service code 55 when completing reports for the court and also for other court related activities.

9. Location Codes • When a client is in a jail/juvenile correctional facility or psychiatric hospital: • The client's location supersedes the location of the clinician. • Always use the correct location code (Jail) or (Psychiatric Hospital) to prevent improper billing. • WHY? These location codes lock-out billing so no overbilling can occur. • Exceptions: • A client at Youth Services Center who is on a General Placement Order (GPO). Do not use jail; instead, use the location code (GPO-Youth Services Center). Services for the youth on a GPO are billable. • Medi-Cal will only pay for 51-case management (discharge planning) services for clients in an acute psychiatric bed. Continue to use the (Psychiatric Hospital) location code and service code 51 if you are communicating about discharge plans.

10. Location Codes • Redwood House – MD services (and case management) may be claimed. • Shelters – all services may be claimed. • Cordilleras (and other IMDs and Psychiatric SNFs) - No services can be claimed. Use correct location code and service code 55.

11. Claiming Time for Progress Notes When a client is a “no-show” for a medication appointment: • Use location code “missed visit”. This location code blocks billing and must be used! • Use service code 15. • Record the time it took you to document the missed visit in Avatar and any other time involved (such as calling the front desk to ask whether the client was there). Do not include "waiting time".

12. Group Notes – MDs and RNs • For Clozaril or other medication support groups: • Write progress notes using the Avatar Progress Note option. • Enter the number of clients who were present, not the number of members of the group. • Enter Service Code 150, Medication Support. The computer will figure the time of service. • If the co-leader is an RN, the nurse can use Service Code 150, Medication Support, and share documentation responsibilities with the MD. Only one note per client should be written. • A mental health counselor, LCSW or LMFT cannot be listed as a co-provider of a Med Support group. The MD/RN needs to write all the progress notes for the group. (The non medical co-provider must do his/her own documentation).

13. Group Documentation • Every note must state the intent, content, and/or focus of the group. This opening material may be the same for every group member. • The rest of the note must pertain specifically to the individual client – his/her response to the group process and individualized assessment of the client’s condition and current needs/issues. • Do not include names of other clients in the note.

14. Travel Time • Site Visits - When an MD travels to another site (residential care facility, contract agency site, etc.), the travel time is divided equally among all clients at that site for whom services were provided. • Behavioral Health Clinics - Travel time between behavioral health clinics cannot be included in time reported for client services.

15. Case Conferences • It is expected that the MD’s contribution to a Case Conference will be primarily around medication management (which includes assessment of the client’s response to treatment). • The MD should write an individual note using service code 17.