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 programs 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 clients
  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).

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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 clients 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 MDs contribution to a
  Case Conference will be primarily around
  medication management (which includes assessment
  of the clients response to treatment).
• The MD should write an individual note using
  service code 17.