Mental Health Medi-Cal Specialty Mental Health Services (SMHS): Private Provider Network (PPN) Outpatient (Non-Hospital) Documentation Training San Francisco Mental Health Plan (SFMHP) Behavioral Health Services (BHS) BHS Quality Management Clinical Documentation Improvement Program (CDIP) staff contact: joe.turner@sfdph.org January 2018
Agenda/Objectives Mins Item Objective 10 Overview: Mental Health Medi-Cal Logic and frame of MH M-Cal Insurance 10 Medical Necessity Required elements and clinical pathways 10 Assessment WHAT is the problem? 10 Treatment Plan of Care (TPOC) WHY does problem exist? 10 Services & Progress Notes HOW to address problem 10 Case Conceptualization & Efficiency Strategies Improve your documentation 2
MENTAL HEALTH MEDI-CAL Medi-Cal Insurance Physical Health Medi-Cal Mental Health Medi-Cal Drug Medi-Cal/ ODS San Francisco Health Plan Blue Cross Partner. Plan BHS (County MHP) BHS (County SUD Plan) Physical health care Mild/Moderate MH care Autism Spectrum/BHT SMHS Moderate to severe MH care SUD Treatment Services San Francisco Mental Health Plan (January 2018) 3
MENTAL HEALTH MEDI-CAL Example Algorithm: Health vs. Mental Health Plan Services (for adult client) List A List B List C Persistent symptoms & impairments after 2 recent medication trials Multiple co-morbid health and mental health conditions Behavior problems (aggressive/selfdestructive/assaultive/extreme isolation) Excessive ED visits or 911 calls Bipolar disorder Trauma/recent loss/significant life stressors Depressive symptoms Anxiety symptoms Homelessness/housing instability resulting from mental health condition ADHD symptoms Lack of diagnostic clarity San Francisco Mental Health Plan (January 2018) 2 or more psychiatric hospitalizations within 12 Functionally significant, non-substance induced paranoia, delusions, hallucinations, mania, dissociative symptoms, depression, personality disorder Suicidal/Homicidal preoccupation with plan or behavior in past year Transitional Age Youth with prodromal psychotic symptoms Eating disorder with medical complications (with medical condition being treated by Health Plan) Substance use disorder not responding to SBI (screening & brief intervention at primary care)
MENTAL HEALTH MEDI-CAL Example Algorithm: Health vs. Mental Health Plan Services for adult client San Francisco Mental Health Plan (January 2018) List A List B List C Persistent symptoms & impairments after 2 recent medication trials Multiple co-morbid health and mental health conditions Behavior problems (aggressive/selfdestructive/assaultive/extreme isolation) Excessive ED visits or 911 calls Bipolar disorder Trauma/recent loss/significant life stressors Depressive symptoms Anxiety symptoms Homelessness/housing instability resulting from mental health condition ADHD symptoms Lack of diagnostic clarity Specialty Mental Health (County MH Plan) 2 or more psychiatric hospitalizations within 12 Functionally significant, non-substance induced paranoia, delusions, hallucinations, mania, >4 from list A or >1 from list B dissociative symptoms, depression, personality disorder Suicidal/Homicidal preoccupation with plan or behavior in past year Non-Specialty Mental Health (Health Plan/Beacon): Transitional Age Youth with prodromal psychotic symptoms Eating disorder with medical complications (with medical condition being treated by Health Plan) <3 from list A and 0 from list B Screening forms (0-4yrs; 5-17yrs; >18yrs) posted to SF Health Plan website Substance use disorder not responding to SBI (screening & brief intervention at primary care)
MENTAL HEALTH MEDI-CAL Area Clinic Model Rehabilitation Model Definition from Federal Social Security Act Treatment Model 1905(a)(9): Clinic services [are those] furnished by or under the direction of a physician, without regard to whether the clinic itself is administered by a physician, including such services furnished outside the clinic by clinic personnel to an eligible individual who does not reside in a permanent dwelling or does not have a fixed home or mailing address Medical model 1905(a)(13): Other diagnostic, screening, preventive, and rehabilitative services, including any medical or remedial services (provided in a facility, a home, or other setting) recommended by a physician or other licensed practitioner of the healing arts [LPHA] within the scope of their practice under State law, for the maximum reduction of physical or mental disability and restoration of an individual to the best possible functional level Recovery model Focus Stabilization Active treatment and participation Locations Clinic-based Community-based Type of Staff Licensed; higher degree professionals Professionals, mental health technicians and peer specialists Organizational Model Organized clinics Organizations that provide one or more covered services San Francisco Mental Health Plan (January 2018) 6
MENTAL HEALTH MEDI-CAL Clinical Practice Conduct assessment Create treatment plan Provide interventions what is the problem? why problem exists how to address it MH Medi-Cal Establish Diagnosis & Functional Impairments Create Treatment Plan/Client Plan Provide Treatment Interventions The Golden Thread of Clinical Practice & Mental Health Medi-Cal San Francisco Mental Health Plan (January 2018) 7
Medical Necessity for SMHS Four Required Elements of Medical Necessity: 1. Included mental health diagnosis 2. Functional impairments (from dx) 3. Treatment interventions (for impairments) 4. Not responsive to physical health care treatment San Francisco Mental Health Plan (January 2018) 8
Medical Necessity for SMHS Four Required Elements of Medical Necessity: 9
Medical Necessity: DIAGNOSIS Diagnosis (Element #1): Your assessment will describe the symptoms, behaviors and differential diagnosis using DSM. Primary MH Dx = Mental Health Medi-Cal Primary SUD Dx = Drug Medi-Cal/ODS Primary Medical Dx = Physical Health M-Cal MH problems 2 to Medical = as above Mild/Moderate MH problems = as above Tip: SMHS = Special Diagnosis one that appears on the DHCS list (not just any old dx!) San Francisco Mental Health Plan (January 2018) 10
Medical Necessity: DIAGNOSIS Diagnosis (Element #1): San Francisco Mental Health Plan (January 2018) 11
Medical Necessity: IMPAIRMENTS Functional Impairments (Element #2): Functional Impairments as a result of the qualifying diagnosis: Symptoms = behavioral expressions/actions associated with the disorder Distractibility in client with ADHD diagnosis Impairments = the consequences/outcomes that ensue for the individual as a result of these behaviors can t pay attention and failing at work can t stop interrupting and loses friends 12
Medical Necessity: IMPAIRMENTS Functional Impairments (Element #2): Functional Impairments as a result of the qualifying diagnosis: A current significant impairment in an important area of life functioning A probability of significant deterioration A probability that the child will not progress developmentally as individually appropriate If full-scope Medi-Cal, under age of 21 years and has a condition as a result of the mental disorder that SMHS can correct or ameliorate 13
Medical Necessity: IMPAIRMENTS Functional Impairments (Element #2): Functional Impairments in an Important Area of Life Functioning: Life Functioning Domains to Explore Living situation Daily activities and functioning Family relations Social relations Finances Legal and safety issues Work and school Health Cultural components Potential for exploitation Source: BHS Documentation Manual (2005 Ed & 2012 Eds.) 14
Medical Necessity: IMPAIRMENTS Functional Impairments (Element #2): 15
Medical Necessity: INTERVENTIONS Interventions (Element #3): The focus of the proposed/actual interventions must address the functional impairment identified as a result of the qualifying mental health diagnosis: Focus = functional impairments Proposed interventions = creating Client Plan Actual interventions = creating Progress Notes 16
Medical Necessity: INTERVENTIONS Interventions (Element #3): Expectation that proposed/actual interventions must do one of the following: Significantly diminish the functional impairment; Prevent significant deterioration in functioning Allow for a child to progress developmentally as individually appropriate Correct/ameliorate the condition for FS-MC, <21 years 17
Medical Necessity: TIP Tip: line up your impairments/interventions these are clinical stories! Functional Impairment Pathway Treatment Interventions Pathway #1: Client has current significant impairments my interventions will significantly diminish impairments #2: Client has probability of significant deterioration my interventions will prevent significant deterioration in functioning #3: Child client has probability of child not progressing developmentally interventions allow the child to progress developmentally #4: Child client has Full-scope Medi-Cal + <21yrs + a condition that SMHS can correct or ameliorate interventions correct or ameliorate the condition 18
Medical Necessity: NOT PHSYICAL Not Responsive to Physical Health Care- Based Treatment (Element #4): The condition/impairment (that exists as a result of a covered diagnosis) would not be responsive to physical health care based treatment. Examples: Depression related to a thyroid condition. Traumatic brain injury that leads to violent behaviors. 19
Assessment Assessment: Assessment in SMHS: Words Matter!! Service: an ACTIVITY to evaluate current mental, emotional, behavioral health (includes MSE, analysis of clinical history, relevant cultural issues, diagnosis); Document: a FORM you fill out annually, or when there is a change in the client s impairments; Phase of Treatment: a PERIOD OF TIME when you are determining medical necessity for services. San Francisco Mental Health Plan (January 2018) 20
Assessment SERVICE Assessment Service: Only bill assessment if you are doing an assessment! a service activity designed to evaluate the current status of a beneficiary s mental, emotional, or behavioral health. Assessment includes but is not limited to one or more of the following: mental status determination, analysis of the beneficiary s clinical history; analysis of relevant cultural issues and history; diagnosis; and the use of testing procedures (CCR Title 9, Section 1810.204) San Francisco Mental Health Plan (January 2018) 21
Assessment Form: Assessment FORM Fill out completely and SIGN/DATE THE FORM! San Francisco Mental Health Plan (January 2018) 22
Assessment PHASE Assessment Phase: Your authorization determines the phase of assessment! Remember-the purpose of an assessment is to determine medical necessity for Specialty Mental Health Services. SIGN AND DATE THE DOCUMENT IT S NOT FINAL UNTIL YOU DO! Never copy/paste documents!!! San Francisco Mental Health Plan (January 2018) 23
Treatment Plan of Care (TPOC) The TPOC/Client Plan is IMPORTANT: The Client Plan must address the mental health needs identified in the current assessment (The Golden Thread assessment impairments). The Client Plan must have Goals/Objectives that address the functional impairments (The Golden Thread assessment impairments). The Client Plan must be updated when there are significant changes in the client s condition (at a minimum, updated Annually). San Francisco Mental Health Plan (January 2018) 24
Treatment Plan of Care (TPOC) The TPOC/Client Plan is IMPORTANT: Document your attempt to get the client s signature on the Client Plan get that signature! The Client Plan is officially finalized when the required staff signature (YOURS) is in place and dated. You must finalize the Client Plan before providing treatment services. In other words, you cannot bill planned services until the Client Plan is finalized you will only be able to bill Plan Development services. San Francisco Mental Health Plan (January 2018) 25
Treatment Plan of Care (TPOC) The TPOC/Client Plan is IMPORTANT: San Francisco Mental Health Plan (January 2018) 26
Services: Case Conference (Plan Development) Case Conference as Plan Development: DHCS has clarified (and BHS/SFMHP has implemented) case conference may be billed as plan development, as follows. CASE CONFERENCE = discussions between direct service providers and other significant support persons or entities involved in the care of the beneficiary. Could be similar or comparable to a multi-disciplinary team meeting; CASE CONFERENCE AS PLAN DEVELOPMENT = If the case conference concerns the development of a treatment plan for a beneficiary, the conference could be claimed as Plan Development San Francisco Mental Health Plan (January 2018) 27
Services: THERAPY Therapy: definition for Medi-Cal Therapy means a service activity that is a therapeutic intervention that focuses primarily on symptom reduction as a means to improve functional impairments. Therapy may be delivered to an individual or group of beneficiaries and may include family therapy at which the beneficiary is present. San Francisco Mental Health Plan (January 2018) 28
Services: THERAPY Therapy: example for Medi-Cal Conducted individual therapy session to address Client Plan Objective ( meet more people so I can find someone to date ). Implemented behavioral rehearsal intervention with client. Client was able to introduce himself and ask an appropriate open-ended question with minimal prompts from therapist. Mental status exam: no change in thought content/ processes from initial meeting. No suicidality observed. 29
Services: PROGRESS NOTE P-I-R-P P-I-R-P Format: Problem = Problem from the treatment plan you are focusing on Intervention = Your interventions and activities that address functional impairments (i.e., significantly diminishing impairments/preventing significant decline) Response = Client s response to your interventions (with details about how/why the interventions work, changes that are needed, etc.) Plan = You and the client s next steps to achieve treatment goals 30
Services: PROGRESS NOTE FORM P-I-R-P Format 31
Case Conceptualization Method #1 Most problematic SYMPTOMS of diagnosis + #2 Functioning DOMAINS impacted by symptoms + #3 HYPOTHESIS of how this works 32
Case Conceptualization Method Client meets criteria for GAD most problematic symptoms are inability to control worry, difficulty concentrating and irritability #1 Client has significant impairment in work domain Due to worry, poor concentration and irritability, the client s work attendance and work performance have declined significantly #2 Client s impairments can be improved Client is unable to recognize/manage symptoms and becomes overwhelmed this leads him to miss work excessively (calls out sick 1-2x/week), make mistakes at work ( zones out and gets lost over worry for 30mins) and is at risk for losing his job ( I ve had 3 verbal warnings ) 33 #3
Case Conceptualization Method Client s impairments can be improved #3 Client is unable to recognize/manage symptoms and becomes overwhelmed this leads him to miss work excessively (calls out sick 1-2x/week), make mistakes at work ( zones out and gets lost over worry for 30mins) and is at risk for losing his job ( I ve had 3 verbal warnings ). DBT interventions can help client make sense of symptoms (psychoeducation), manage symptoms (mindfulness, distress tolerance) and reduce work impairments (implement calming skills and tools in vivo). Weekly therapy sessions will initially focus on reducing client s level of stress and psychoeducation. Teaching and practicing skills will occur in session, at home & at work. 34
IMPLEMENTING Documentation Efficiency Tips Stop copying/pasting and start answering the question being asked (read the prompts on the forms and directly address them); Don t leave blanks on the forms (e.g., not yet assessed, insufficient information to rate, etc.); Prioritize Assessment items (presenting problem; relevant conditions; risks/strengths; mental status exam; case formulation); Easy access to source documents (documentation manual, instructions for forms) 35
Do what the auditors do! PRACTICE! Assessment & Diagnosis criteria (behaviorally specific; included list; sign the form); Impairment criteria (current significant/risk of significant decline); Intervention Criteria (reducing the current significant/ preventing risk of significant decline); Not Physical Health Care-Based Treatment criteria 36
Treatment Authorization Request! Initial Treatment Authorization Request (TAR) Required prior to delivery of service! 37
Treatment Authorization Request! Initial Treatment Authorization Request (TAR) Required prior to delivery of service! 38
Treatment Authorization Request! ONGOING TAR Medical Necessity Attestation for Continued Treatment 39
Treatment Authorization Request! ONGOING TAR Medical Necessity Attestation for Continued Treatment Attestation: confirm that all of the elements of medical necessity Level of Care Confirmation: the client s mental health needs may/may not be met at this level we need to check! 40
Treatment Authorization Request! ONGOING TAR Medical Necessity Attestation for Continued Treatment 41
Treatment Authorization Request! ONGOING TAR Medical Necessity Attestation for Continued Treatment Client s progress: significant impairments are being significantly reduced? Prevention of significant decline in functioning? Rationale for Continued Treatment: What is the current status of the client? What are the functional impairments? What are the mental health needs! 42
Questions and Thoughts? Wrapping Up Resources: Must haves are 2017 Documentation Manual, Desk Reference & guidance from authorizing body (BHAC, FCMH, FMP, etc.) BHS URL: https://www.sfdph.org/dph/comupg/oservices/mentalhlth/cbhs/ CDIP URL: https://www.sfdph.org/dph/comupg/oservices/mentalhlth/cbhs/cbhsqualitymgmt.asp BHS Compliance: chona.peralta@sfdph.org; BHS Documentation Improvement: joe.turner@sfdph.org 43