Drug Medi-Cal CALIFORNIA CODE OF REGULATIONS Title 22, Section Patient Record Requirements

Transcription

1 Drug Medi-Cal CALIFORNIA CODE OF REGULATIONS Title 22, Section Patient Record Requirements Jenaro Valdez ADP Service Specialist Alcohol Drug Program County of Santa Barbara September

2 Questions to: State of California or County of Santa Barbara 2

3 ACA: TREATMENT INTEGRATION and CARE Clients with substance use disorders have a high rate of medical comorbidity. Treatment is more successful if all of a client s health needs are addressed in a coordinated approach. Thus, programs should take steps to provide integrated and coordinated care. SAMSHA, Working with Medical and Other Programs to Enhance Treatment Integration. 3

4 ACA: Reasons for Integrated Care Substance use and medical problems often co-occur, yet treatments often are not coordinated. Reasons for Integrated Care: New ways are needed to increase screening for and treatment of substance use disorders. (SBIRT) A holistic focus on a person s medical and behavioral health needs improves the quality of care for each client. Substance use and medical problems often co-occur, yet treatments often are not coordinated. The Affordable Care Act highlights integration as one way to improve access to care and help improve outcomes for patients. 4

5 Drug Medi-Cal Provider Responsibility 5 THE PROVIDER SHALL Establish, maintain, and update as necessary, an individual patient record for each beneficiary admitted to treatment and receiving services. For purposes of this regulation, an individual patient record means a file for each beneficiary which shall contain, but not be limited to, information specifying the beneficiary's identifier (i.e., name, number), date of beneficiary's birth, the beneficiary's sex, race and/or ethnic background, beneficiary's address and telephone number, beneficiary's next of kin or emergency contact, and all documentation relating to the beneficiary gathered during the treatment episode, including all intake and admission data, all treatment plans, progress notes, continuing services justifications, laboratory test orders and results, referrals, counseling notes, discharge summary and any other information relating to the treatment services rendered to the beneficiary.

6 Admission To Treatment Date Definition: The date of the first face-to-face treatment service. This date will be used to start the clock for meeting all the timeline requirements in Title 22 (ie, 30 days for the ITP to be completed and signed by the counselor, then15 days for MD to sign the ITP). Also, the Justification to Continue Tx renewal date. Section (b)(1) 6

7 Admission Process: Establish Medical Necessity Medical Necessity is the critical issue in the provision of Drug Medi-Cal substance abuse services. Why? DMC funded Tx services is a medical model. The funds are a carve out of federal Medicaid health benefits. Services must be prescribed by a physician, and provided by or under the direction of a physician. [ (a) & (h)]. Without the MD determining Medical Necessity, your agency cannot get reimbursed by DMC, they can lose money The Medical Necessity forms provide verification that these requirements have been met. 7

8 1. Medical Necessity Requires 8 1. Must be and remain a Medi-Cal beneficiary at all times. 2. Complete ADP Health Questionnaire. Determines fitness for Tx. (reviewed by staff and MD). 3. Must have document a personal history (social, family, substance use and Tx history). ASI will suffice. 4. Requires a recent physical exam (previous 3 mos) or Medical Waiver (signed by MD). 5. The physician s signature on the initial and any subsequent treatment plans developed by Tx counselor, within the DMC timelines. 6. Assignment of a substance use DSM-IV-TR diagnosis. 7. Verification of Medical Necessity Form (signed by the MD) only after a review and completion of the above documents.

9 2. CA ADP Health Questionnaire What should you look for? Central question is: Is the client s medically fit for Tx? What medical conditions should you be aware of? Include tobacco in drugs used, and how much use After a review of the HQ, what medical issues should be on the Tx plan for follow up with primary care? Should a Wellness goal be on a Tx plan? What might be wellness interventions on a Tx plan: See page 8 Wellness Interventions examples: medication compliance, diet, nutrition, meditation, exercise, and smoking cessation are just a few you could include. 9

10 3. Personal History (ASI) ASI is the standard assessment tool required in your contract with the County of Santa Barbara. At a minimum, assesses the areas that meet the DMC requirements social, family, substance use and Tx history for helping to establishing medical necessity Clinically, try to find out the evaluation or analysis of the cause or nature of mental, emotional, psychological, behavioral and substance abuse disorders Title 22, (b)(10) Title 22, (h)(1)(A)(ii) 10

11 4. Recent Physical Exam or Waiver Only the MD can sign the physical exam waiver, based on the client s information in the health questionnaire. The MD has three options on the physical exam waiver: 1. Admit to Tx without reservations 2. Admit to Tx with reservations (MD might say the client needs a TB or dental exam or other). In this case, follow up and put it in the initial Tx plan or develop a (Wellness Goal?) 3. The third MD option is denial of admission based on health history and determination of not fit to treat at this time. 11

12 Physical Exam or Waiver Cont d The Physical Exam Waiver must explicitly waive the physical exam, and must state a basis for the waiver (DMC Physical Exam Waiver Form). Preferred language: Based on my review of the beneficiary s (1) medical history, (2) substance abuse history and/or most recent physical exam, I waive the admission physical exam. Without these documents, the MD does not have a basis for signing a Physical Exam Waiver! 12

13 5. MD Signature on TX Plan Must be signed by an MD within 15 days after the SUD Counselor signs a Tx plan. Without an MD signature, Tx services with clients are not reimbursable. Worse, if medical necessity is never established, all Tx services after that date would be disallowed in an audit That is why it is medical necessity is the critical issue 13

14 6. Assignment of a DSM IV- TR Diagnosis 14 The DSM IV-TR diagnosis must be on the Tx plan. Is it Abuse or Dependence? DSM IV-TR says defines abuse as: A maladaptive pattern of substance use, leading to clinically significant impairment of distress, as manifested by one (or more) of the following, occurring at any time in the same 12- month period: 1. Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performances related to substance use, substance related absences, suspensions, or expulsions from school; neglect of children or household. 2. Three others related to use in physically hazardous, legal problems, social or interpersonal problems (fights, arguments with wife )

15 Assignment of a DSM IV-TR Diagnosis Cont d DSM IV-TR defines dependence as: A maladaptive pattern of substance use, leading to clinically significant impairment of distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period: 1. Tolerance 2. Withdrawal 3. Substance taken in larger amounts 4. Persistent desire or efforts to cut down use or control substance use 15

16 7. Verification of Medical Necessity Verification of Medical Necessity Form: Several documents are needed before the MD signs this form. Verification form states: Following a review of the client s Medical, Substance History and of the Initial Treatment Plan, I hereby affirm that, based on the problems outlined in this plan, the client s diagnosis-in accordance with DSM IV-TR diagnostic categories - is appropriate and indicates that there is medical necessity for this client to be in treatment for substance abuse or dependence and related medical, psychological and social problems. 16

17 7. Verification of Medical Necessity Cont d RECAP: Only after, social, family, substance use and Tx history (ASI). 1. Physical exam or waiver 2. Individualized initial Tx plan with a DSM diagnosis 3. Only after these have been reviewed by the MD can he/she sign and/or determine that it is medically necessary to treat the individual for (DMC purposes). 17

18 7. Medical Necessity Cont d This entire admission process helps establish initial medical necessity. As a result, any incorrect or missing information means that medical necessity has not been established and all claims for tx services will be disallowed in any audit. Q. What else does it take to continue medical necessity as Tx continues for a period of time? A. (hint 5 mos before 6?). 18

19 Five Types of ODF Individual Counseling under Title 22 DMC ODF Tx is primarily a group modality. It allows for five (5) individual counseling types with different requirements for each. These 5 are: 1. Intake (2 parts, Admission and Assessment) 2. Treatment Planning 3. Collateral Services 4. Crisis Intervention 5. Discharge Planning 19

20 Intake Two Parts: Admission and Assessment 20

21 1. Intake/Admission 21 Definition (CCR, Title 22, (b) (10)): Intake means the process of admitting a beneficiary into a substance abuse treatment program. Intake includes the evaluation or analysis of the cause or nature of mental, emotional, psychological, behavioral, and substance abuse disorders; the diagnosis of substance disorders utilizing the Diagnostic and Statistical Manual of Mental Disorders Third Edition- Revised or Fourth Edition, published by the American Psychiatric Association; and the assessment of treatment needs to provide medically necessary treatment services by a physician licensed to practice medicine in the State of California. Intake may include a physical examination and laboratory testing (e.g. body specimen screening) necessary for substance abuse treatment and evaluation conducted by staff lawfully authorized to provide such services and/or order laboratory testing within the scope of their practices or licensure.

22 Intake Cont. 22 Face-to-face meeting between the SUD counselor and the beneficiary. Date of that first face to face session should be used as the admission date to treatment on all forms (CalOMS, Individualized Tx Plan, Justification to Continue Tx.) You have 30 days to complete all the intake and treatment planning activities in order prepare and complete the ITP, signed by counselor. It is advised not to use the other individual counseling services in the first month because of the time frame of 30 days. Telephone contacts, home visits and hospital visits do not qualify services must be provided at the certified DMC program facility. Field trips not reimbursable Section (b)(9)

23 Intake Activities 23 Areas/activities that are billable in connection with admission of a beneficiary to a SUD Tx program: Admission process and establish medical necessity! Evaluation or analysis of the cause or nature or mental, emotional, psychological, behavioral, and substance abuse disorders usually provided by providers via the use of the ASI, Gain, Paddi Diagnosis Assessment of Tx needs 1. Admission program information given to the beneficiary, participation agreements, program policies and rules, financial assessment and determination of program fees are all typical forms that need to be filled out during an intake process for all Santa Barbara County ADP DMC providers Example of typical admission forms: TB screening Client /Appeal Rts. HIPPA-Privacy Rights/Duty to Warn Consent to Treat/ROI Participation agreement Financial assessment program fees Medical and substance abuse history Physical examination waiver Verification of medical Nec.

24 2 nd Part: Assessment Needs 24 Require, at minimum, assessment of treatment needs in the following life domains: Education (truancy, GPA, social) Employment/Vocational (Do they need a job, training) Financial (debt, security, savings) Legal services (do they need a lawyer) Medical and Dental services Psycho/Social (what is needed, hobbies, recreation needs Drug Use/Tx history

25 Standard Assessment Tools 25 SB County ADMHS ADP requires the use of standard assessment and screening tools and other tools to be used in the intake process. These include: ASI (Addiction Severity Index), 5 th Ed ASI English and Spanish versions, GAIN, TSI PADDI Diagnostic and Statistical Manual of Mental Disorders, 4 th Ed Rev (DSM IV-TR) American Society of Addiction Medicine, Placement and Assessment Criteria, 2 nd Ed, Rev (ASAM PPC-2R) Stages of Change Readiness Scale Specific requirements needed in the medical and drug history, of which some assessment tools might not address, include the identification of: Drug of choice, include nicotine use! Date of first use Dosage Pattern/History of use including onset of problem/addictive use Date of last use SUD TX history, Attempts? location of past Tx attempts

26 Intake/Assessment Limitations There are no limitations on the number of intake sessions that may be provided a beneficiary. However, counselor has 30 days to conduct all intake activities in order to complete and sign the ITP. All intake activities must be clinically justified and properly documented in the progress notes section of the patient chart according to the specific individual service being provided. Progress note requirements are different for all the 5 individual services. 26

27 Treatment Planning It s all about getting as close to the target as possible! 27

28 Treatment Planning Definition (CCR, Title 22, (h) (2) (A)):The provider shall prepare a written individualized treatment plan, based upon the information obtained in the intake and assessment process. 28

29 Tx Planning Because it is also impractical or impossible to exactly pre-plan other types of billable individual counseling sessions, it is acceptable to make a blanket statement of individual counseling sessions as necessary on the treatment plan, except for collateral sessions!. CA ADP DMC Training Manual 29

30 Treatment Planning Activities Days. The counselor should review all of the information gathered during the intake process to review with the beneficiary and prepare an ITP. When writing the ITP, clients will be provided SUD tx services that are indicated by the diagnostic and assessment tools and information obtained from the client in the admission process Consider the clinical recommendations from other treatment providers. Work with the beneficiary in a collaborative manner to mutually agree on achievable treatment goals 90 Days. The counselor should review the treatment plan no later than ninety (90) calendar days after signing the initial treatment plan, and no later than every ninety (90) calendar days thereafter, or when a change in problem identification or focus of treatment occurs (Title 22, sec (h), (2), (A), (iii) (a) The specific treatment plan requirements for Title 22 are: A DSM IV-TR diagnostic code must be established A Statement of Problems to be addressed in the Tx plan Goals to be reached which address each problem Action Steps/Interventions that will be taken by the provider and/or beneficiary to accomplish identified goals Target dates for the accomplishment of action steps and goals A description of the services, including the type of counseling, to be provided and the frequency thereof ( the prescription ); and The assignment of a primary counselor

31 Tx Goals 31 What are the areas for Tx goals? Obviously, drugs/etoh, but also some of the more immediate issues that can relieve the stress and anxiety of the client and family/school/work. Problems identified in the problem statement in the Tx plan, based on your complete assessment. Truancy, job, family, legal, peer pressure, significant others Should a wellness goal be on a Tx plan? What might be wellness interventions on a Wellness Goal: Wellness interventions: medication compliance, diet, nutrition, meditation, exercise, and smoking cessation. Do not overload goals on the client! Look at recovery as a long term process. They did not get there overnight, so balance their Tx plan for long term recovery! Include social/recreational needs of client. Some client say they relapse because life is boring!

32 Treatment Planning Limitations There are no limitations on the number of treatment planning sessions that may be provided to a beneficiary. All TP activities must be clinically justified and prescribed in the ITP as one of the SUD treatment services to be provided during the course of Tx 32

33 Tx Plan Review When conducting a treatment plan review (every 90 days), or when a change in problem identification or focus of treatment occurs, you are required to update the beneficiary s ITP, otherwise a treatment planning session may be disallowed. When to do a Tx plan update: When significant health changes occur (pregnancy, physical injury, discovery of a chronic health problem), changes in relationships, loss of housing or income, disclosure of a problem in group session etc; all could be new problems that may impact treatment or require a change in treatment focus, hence a revised ITP 33

34 Treatment Plan Timelines Within 15 calendar days of signature by the counselor, the physician shall review, approve and sign all updated treatment plans. If the physician has not prescribed medication, a Psychologist, licensed by the State of California Board of Psychology may sign an updated treatment plan. Section (h)(2)(A)(iii)(b) 34

35 Collateral Services I am not convinced I should help the little guy yet! 35

36 Collateral Services Cont. Definition (CCR, Title 22, (b) (3)): Collateral services means face-to-face sessions with therapists or counselors and significant persons in the life of a beneficiary, focusing on the treatment needs of the beneficiary in terms of supporting the achievement of the beneficiary s treatment goals. Significant persons are individuals that have a personal, not official or professional, relationship with the beneficiary. 36

37 Collateral Activities Collateral is not a family session! Title 22 does not fund family sessions. A collateral seeks to achieve a better understanding of a client s past use of illicit substances or contribute to a better understanding of the nature of addiction and be able to assist the client in achieving Tx goals. The progress notes should reflect the definition provided in Title 22 regulations Another reason for a collateral session is to assess the family of the client. What roles do they play? Who supports the behaviors of drug use in the home. Is there codependency present? To enhance Tx success, collateral sessions should be attempted with all individuals in Tx. 37

38 Collateral Session 38 Example of a progress note on a collateral session: 11/19/2012 9am- 9:50am Individual Counseling/Collateral A collateral session was held with the parents of the client and explored the identification of stressors in the family home that might affect the beneficiary in their efforts to remain abstinent. As a result of the session, a much thorough picture of identifying the areas of environmental concern may now be better addressed in the Tx goal #1: Abstain from illicit drug use. A collateral session is the only one of the individual counseling sessions in which a client need not be present Collateral services, if they are to be provided, must be clearly written in the patient s ITP. Failure to indicate a collateral service in the Tx plan and the number and frequency of sessions (amount in a month) is cause for a disallowance of these services!

39 Collateral Limitations 39 Question: Can collateral sessions be used to convince/neutralize family members wanting to sabotage a family members abstinence? (picture of the puppy trying to decide if it should be part of the recovery team) There are no limitations on the number of collateral sessions that may be provided to a beneficiary Collateral sessions must be clinically justified and prescribed in the ITP Title 22 states: Collateral services shall be documented in the beneficiary s treatment plan in accordance with the beneficiary s short/long-term goals. The beneficiary s progress notes shall specifically reflect the steps taken to meet the goals defined in the beneficiary s treatment plan

40 Crisis Intervention 40

41 Crisis Intervention Cont. Definition (CCR, Title 22, (b) (5)): Crisis intervention means face-to-face contact between a therapist or counselor and a beneficiary in crisis. Services shall focus on alleviating the imedicate crisis. Crisis means an actual relapse or an unforeseen event or circumstance which presents to the beneficiary an imminent threat of relapse. Crisis intervention services shall be limited to stabilization of the beneficiary s emergency situation. 41

42 Crisis Intervention Activities 42 When billing for Drug Medi-Cal, the most important elements needed to justify and address a crisis situation is first, the crisis must: Be an actual relapse or an unforeseen event and All interventions must be limited to stabilization of the emergency situation All clients by nature of their being clients are in some state of crisis. The core function of crisis intervention, however, relates to the counselor s services to their client when there has likely been some precipitating event to shift the client from the usual state of conflict or crisis to an intense state of acute distress In addition, if the crisis session is a same day, second unit of service, it must meet the following criteria for reimbursement for Title 22: A multiple billing override must be filled out and located within the chart file You must state in the progress notes that the second visit was necessary and all services could not be conducted in one visit You must also state in the progress notes that the return visit was not a hardship on the client

43 Crisis Intervention Limitations There are no limitations on the number of crisis sessions that may be provided to a beneficiary. However, if there are too many crisis sessions being provided, it may indicate that intensive Tx services or higher level Tx modality is warranted and an update on the Tx plan should be considered. Either way, the PN should justify why you kept or discharged the client or what intervention you took as a result of the frequency of crisis sessions. Crisis sessions or acute interventions must be clinically justified and documented in progress notes, according to the requirements and definition outlined in Title 22 43

44 Discharge Planning 44

45 Discharge Planning Cont. Definition (CCR, Title 22, (b) (3)): For outpatient drug free, day care habilitative, perinatal residential, and Naltrexone treatment services, the provider shall complete the discharge summary within thirty (30) calendar days of the date of the last face-toface treatment contact with the beneficiary. The discharge summary shall include: 45

46 Discharge Planning Activities 46 The duration of the beneficiary s treatment as determined by the dates of admission to and discharge from treatment For narcotic treatment program services, the discharge summary shall meet the requirements of Section 10415, Title 9, CCR In addition, the discharge of a beneficiary from treatment may occur on a voluntary or involuntary basis. If it is involuntary, it is subject to the requirements set forth in Subsection (p) of Title 22, which is the right to a fair hearing A summary and description of the overall level of functioning subsequent to the initial assessment should include the following in the Discharge Summary Form: Has the client been drugfree in the last 30 days before discharge? Legal status/criminal activity Vocational/educational achievements Living/housing situation List referrals made Clients prognosis What is the reason for discharge

47 Discharge Planning Activities 1. Exit ASI (only after a year in SUD treatment) Primary focus is on the drug and alcohol elimination or reduction 2. CalOMS Discharge 3. Discharge Summary Form 4. Discharge Plan with referals 5. The last progress note should indicate the formal closure of the chart and stating that the four activities outlined above were completed. I recommend not using discharge planning in the first month of tx because of the use of other Tx planning sessions available and the 30 day DMC timeline req. 47

48 Discharge Planning Limitations There are no limitations on the number of discharge planning sessions that may be provided to a beneficiary or a specific period of time when a discharge planning session can occur. All sessions must be clinically justified and documented in progress notes. 48

49 Modality Requirements ODF Group counseling and limited individual counseling. Regular and perinatal. DCH Group and individual counseling. (Intensive ODF) EPSDT and Perinatal beneficiaries ONLY. Perinatal Residential Group and individual counseling and other individual services. Perinatal only, 16 or fewer clients in a residential setting. Section (d)(1)-(4) 49

50 Group Counseling Face-to-face contact One or more therapists or counselors Focused on the needs of the individuals DMC-ODF must be from 4 to 10 in the group Requires one DMC client, therefore non DMC clients can be in the group. Section (b)(8) 50

51 Day Care Rehabilitative (Intensive Tx) Outpatient counseling and rehabilitation services Minimum of three hours a day, three days a week Limited to pregnant or postpartum women, and/or Early and Periodic Screening, Diagnosis and Treatment (EPSDT) eligible beneficiaries Section (b)(6) 51

52 Perinatal Postpartum A pregnant woman who was eligible for and received Medi-Cal during the last month of pregnancy, shall continue to be eligible for all pregnancy related and postpartum services, for a 60-day period beginning on the last day of pregnancy, regardless of whether the other conditions of eligibility are met. Eligibility for this program ends on the last day of the month in which the 60th day occurs. Section (b)(18) 52

53 Perinatal Services Drug Medi-Cal substance abuse services for pregnant and postpartum women: (1) Any of the substance abuse services listed in subsection (d) of this regulation shall be reimbursed at enhanced perinatal rates pursuant to Section (a)(3) only when delivered by providers who have been certified pursuant to Section to provide perinatal Medi-Cal services to pregnant and postpartum women. (2) Only pregnant and postpartum women are eligible to receive residential substance abuse services. (3) Perinatal services shall address treatment and recovery issues specific to pregnant and postpartum women, such as relationships, sexual and physical abuse, and development of parenting skills. (4) Perinatal services shall include: 53

54 Perinatal Services PERINATAL SERVICES (A) Mother/child habilitative and rehabilitative services (i.e., development of parenting skills, training in child development, which may include the provision of cooperative child care pursuant to Health and Safety Code Section ); (B) Service access (i.e., provision of or arrangement for transportation to and from medically necessary treatment); (C) Education to reduce harmful effects of alcohol and drugs on the mother and fetus or the mother and infant; and (D) Coordination of ancillary services (i.e., assistance in accessing and completing dental services, social services, community services, educational/vocational training and other services which are medically necessary to prevent risk to fetus or infant). 54

55 Documenting Treatment Treatment services must be documented through progress notes. Progress note requirements are different for ODF and DCH/Perinatal Residential modalities. ODF are for each Tx session. DCR are weekly summaries 55

56 Documenting Treatment Progress notes for ODF: 56 Must be legible Must be individual narrative summaries Must be completed for each counseling session (CA ADP cert standards requires a counselor signature, DMC doesn t) Must include attendance information including full date (month, day, year), session duration and type of counseling (individual and type or group. The DAP Must include a description of beneficiary progress on treatment plan goals, interventions, etc. Section (h)(3)(a)

57 Good Progress Note Indicate progress on Tx plan goals by writing good progress notes. Should read like a story. Good: (90 min) 10:00 to 11:30 am) Group counseling. Topic: Triggers. Beneficiary demonstrated an understanding of relapse triggers by sharing that rainy days brings depresses them and makes them feel like drinking alcohol.tp goal 1 Plan to keep demonstrating knowledge of triggers by client. Bad: min. Individual Counseling Beneficiary was awake and said when it rains he/she feels like having a drink What is missing in the bad note? Step by step. 57

58 Minimum TX Sessions A minimum of two counseling sessions per 30-day period In DMC-ODF, the beneficiary must receive a minimum of two group counseling sessions per month. Section (d)(2)(a) Q. What happens when my client returns to jail for a short time while in Tx? Do I discharge them? Next page 58

59 Minimum TX Sessions Ans. Minimum requirement may be waived by the provider if: the beneficiary is making progress towards treatment plan goals Section (h)(4) If fewer contacts are clinically appropriate Exceptions or waivers must be noted, signed and dated by the physician in the beneficiary s treatment plan. DMC trumps CalOMS! Section (i)(4) 59

60 Continuing Services Justification 60 No sooner than five months and no later than 6 months from the admission date or the date the last stay review was completed. The timeline on the stay review never changes! Counselor must review progress and eligibility of beneficiary to continue tx services. The stay review should be objective with data for your justification to continue Tx. Utilize: 1. urine tests-do they show steady progress? 2. progress notes-is the client making PROGRESS on the Tx plan? What is the client s attendance record? 90% attendance? 3, Compare drug history from intake (ADP Health Questionnaire) to current usage. Section (h)(5)(a)(i)