Documentation in Individual/Group

Practitioner Medical Record

Important Provider Information can be located at:• ValueOptions-Maryland; “For Providers”; “Provider Information”

– Claims/Finance– Clinical/Utilization Management– Compliance (VO Audit Tools)

• ValueOptions-Maryland; “For Providers”; “Provider Alerts”– DHMH Provider Alerts– ValueOptions Provider Alerts

• ValueOptions-Maryland; “For Providers”; “Provider Manual”– Service Descriptions– Medical Necessity Criteria for Use by Maryland PMHS

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Webinar Objectives

Participants will be able to:

• Locate relevant information pertaining to Individual/Group Practices on the ValueOptions-Maryland website

• Learn who is authorized to serve as an Individual Practitioner under the PMHS

• Identify COMAR citations related to Individual Practitioners

• Identify the required elements of a consumer medical record

Definitions• MENTAL HEALTH PROFESSIONALMENTAL HEALTH PROFESSIONAL: an individual who is licensed, certified,

or otherwise legally authorized to provide the mental health service: under Health Occupations Article, Annotated Code of Maryland; or in the state where the service is rendered. COMAR 10.21.17.02 B (42)

• PROFESSIONAL COUNSELORPROFESSIONAL COUNSELOR: an individual who is certified or licensed and legally authorized to practice as a professional counselor: under Health Occupations Article, Annotated Code of Maryland; or in the state where the service is rendered. COMAR 10.21.17.02 B (55)

• PSYCHIATRISTPSYCHIATRIST: a physician who: is certified in psychiatry by the American Board of Psychiatry and Neurology; or has completed the minimum educational and training requirements to be qualified to take the Board of Psychiatry and Neurology examination for certification in psychiatry. COMAR 10.21.17.02 B (42)

Definitions• PSYCHOLOGISTPSYCHOLOGIST: an individual who is licensed and legally authorized to

practice as a psychologist: under Health Occupations Article, Annotated Code of Maryland; or in the state where the service is rendered. COMAR 10.21.17.02 B (61)

• SOCIAL WORKERSOCIAL WORKER: an individual who is licensed and legally authorized to practice as a social worker: under Health Occupations Article, Annotated Code of Maryland; or in the state where the service is rendered. COMAR 10.21.17.02 B (78)

DefinitionsSee COMAR 10.21.25.03 B (7) (a-i)

"Individual practitioner" means:

A CERTIFIED REGISTERED NURSE PRACTITIONER—CERTIFIED REGISTERED NURSE PRACTITIONER—PSYCHIATRIC PSYCHIATRIC (CRNP—P) who is:

• Licensed and legally authorized to practice as a certified registered nurse practitioner—psychiatric in the state in which the service is rendered to perform independently the services set forth in COMAR 10.27.07; and

• Certified by the Maryland Board of Nursing or an equivalent board of nursing in another state as a certified registered nurse practitioner with a specialty in psychiatry pursuant to COMAR 10.27.07 and demonstrates, by training and experience, the competency to provide the mental health services;

Definitions (Individual Practitioner-continued)

A PHYSICIAN PHYSICIAN who: • Is licensed and legally authorized to practice as a physician

in the state in which the service is rendered, and demonstrates, by training and experience, the competency to provide mental health services;

A PROFESSIONAL COUNSELOR PROFESSIONAL COUNSELOR who is licensed and legally authorized to practice as a clinical professional counselor in the state in which the service is rendered;

Definitions (Individual Practitioner-continued)

A PSYCHOLOGIST PSYCHOLOGIST who: • Is licensed and legally authorized to practice as a

psychologist in the state in which the service is rendered, and • Demonstrates, by training and experience, the competency to

provide mental health services;

A PSYCHOLOGY ASSOCIATE PSYCHOLOGY ASSOCIATE who is authorized by the Maryland Board of Examiners of Psychologists to practice as a psychology associate and demonstrates, by training and experience, the competency to provide mental health services; or

A SOCIAL WORKER SOCIAL WORKER who is licensed and legally authorized to practice as a clinical social worker in the state in which the service is rendered.

Staffing Requirements/LimitationsSee DHMH/MHA October,2008 Compliance with Medicaid Requirements and Billing the PMHS

The practice of employing graduate-level clinicians and receiving reimbursement for clinical services under the Public Mental Health System (PMHS) is DISALLOWEDDISALLOWED. LCSWs, LGSWs, and LGPCs cannot practice independently and ARE NOT ARE NOT considered “individual practitioners” under MHA regulations.

The fee schedule as specified in COMAR 10.21.25.05 A for treatment services in part, distinguishes between Outpatient Mental Health Center (OMHC) case rates and the case rates of LCSW-Cs and LCPCs. There is NO CASE RATE NO CASE RATE for graduate level clinicians nor licensed certified social workers in individual practitioner settings.

In summary, only licensed mental health professionals authorized to practice independently may provide mental health services and receive reimbursement in the PMHS.

Individual Practitioner Regulations

Licensed Social Workers (LCSW)• COMAR 10.42.01

• COMAR 10.42.03

Licensed Counselors (LCPC)• COMAR 10.58.01

• COMAR 10.58.03

Psychologists (Ph.D.)• COMAR 10.36.05

All Individual Practitioners:COMAR 10.21.25.03-1 H & I

Medical Record Content

• Informed Consent for Treatment

• Comprehensive Assessment

• Treatment Planning

• Contact Note Documentation

• Referrals/Collaboration (LCPC, PhD)

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Consent for TreatmentSee COMAR 10.21.25.03-1 H (1) (a); LCSW: COMAR 10.42.03.03 A (1-4); LPC: COMAR

10.58.03.04 A (5-6); LPC: COMAR 10.58.03.08 A (5);  Ph.D: COMAR 10.36.05.08 C (2)

Consent for services is documented by signature of the consumer or, when applicable, legal guardian. In instances when this is not possible, the program shall document the reasons why the individual cannot give written consent; verify the individual’s verbal consent; and document periodic attempts to obtain written consent.

Apprise the client of the risks, opportunities, and obligations associated with services available to the client;

Consent for Treatment—Continued

The estimated cost of treatment; Make the fee for service clear, maintain adequate financial records, and confirm arrangements for financial reimbursement with the client;

Per COMAR 10. 09.36.03 A (6) a provider shall accept payment by the Program as payment in full for covered services rendered and make no additional charge to any person for covered services.

Per an April 14, 2004 DHMH memorandum entitled Billing Medicaid Recipients for Missed Appointments, “…current federal policies prohibits providers from billing Medicaid recipients for any missed appointments. The Centers for Medicare and Medicaid Services (CMS) has recently confirmed this policy to the Department”.  

Consent for Treatment—Continued

The right of a client to withdraw from treatment at any time, including the possible risks that may be associated with withdrawal; and

The right of a client to decline treatment, if part or all of the treatment is to be recorded for research or review by another person

Consent for Treatment—Continued

In instances of MINOR CONSUMERS MINOR CONSUMERS who are under the care and custody of an individual other than the parent (i.e. extended family member, DSS, foster parent), it is strongly recommended that legal documentation in the form of court orders or custody agreements be obtained and included as part of the medical record.

Additionally, if consumers are court ordered to mental health treatment, it is recommended that a copy of the court order or correspondence from the probation officer should be obtained and included as part of the medical record.

The treating clinician or individual facilitating the consumer’s admission should also witness consumer/parent/guardian signature via his/her dated signature on the consent.

Comprehensive AssessmentRefer to Maryland Medical Necessity Criteria: Level of Care VI:

Outpatient Services ICD-9 Crosswalk and PMHS Diagnoses-February, 2012 for guidance regarding ICD-9 Codes that are reimbursable by the PMHS pursuant to COMAR 10.09.70 and MNC for outpatient services

The comprehensive assessment includes the:

Individual or family’s presenting problem;

Individual or family’s history

Individual’s diagnosis; and

Rationale for the diagnosis

Comprehensive Assessment—Continued

For best practice, the assessment should also include:

substance abuse history (if any),

mental status exam,

a review of diagnosis by a physician if an organic determinant is involved or treatment with medication is indicated.

Comprehensive Assessment—Continued

For best practice, the assessment for children should also include:

level of functioning and availability of family and other social supports,

developmental history, educational history and current placement,

home environment, evaluation of the current family status, including legal custody status,

development of motor/language/self-care skills and

history, if any, of substance abuse, physical/sexual abuse, out of home placement, involvement of the local Department of Social Services or the Department of Juvenile Services.

Treatment PlanningSee LCSW: COMAR 10.42.03.03 A (5) (a-b); LPC: COMAR 10.58.01.02 B

(8) (a-e) and COMAR 10.58.03.05 A (1) (a); PhD: COMAR 10.21.25.03-1 H (1) (c)

The record contains an INDIVIDUALIZED TREATMENT PLAN INDIVIDUALIZED TREATMENT PLAN that includes the: problems, needs, strengths, goals that are measurable;

interventions that are medically necessary;

signatures of the individual, or if the individual is a minor, the guardian, and the treating mental health professional.

For best practice, treatment plan reviews should be updated to reflect consumer progress in treatment. The plan should reflect any referrals/collaborations with outside agencies; goal changes based on a review of progress; changes in treatment strategies; and changes in diagnosis, if any.

Contact NotesSee COMAR 10.21.25.03-1 H (2); LCSW: COMAR 10.42.03.03 A (5) (b-

c), COMAR 10.42.01.02 B (5) (c-d); LPC: COMAR 10.58.01.02 B (9); PhD: COMAR 10.36.05.08 C (2)

The contact note shall include:

Date of service;

Start time and end time;

Location;

Summary of interventions provided; and

The treating mental health professional’s signature and date of service.

For best practice, the contact note should also include: chief medical complaint/reason for the visit; consumer’s mental status; the delivery of services specified by the ITP; a brief description of the service provided; the plan for changes in treatment (if any); the consumer’s progress towards goals

Referral/CollaborationSee PhD: COMAR 10.36.05.08 C (2); LCPC: COMAR 10.58.01.02

B (8) (e) For Ph.Ds.Ph.Ds.– The consumer’s original test data and results and

the results of any formal consultations with other professionals is documented in the record.

For LCPCsLCPCs– When clinically indicated, the clinician has referred the consumer to additional services and/or collaborated with outside agencies. The clinician has documented the consumer declining any potential referrals for additional services. The clinician documents efforts to link the consumer to additional services.

2013 CPT Code Changes

• The American Medical Association (AMA) released major changes to the Current Procedural Terminology (CPT®) codes.

• The new code set applies to all services provided on or after January 1, 2013.

• All provider disciplines are impacted (psychiatrists, psychologists, social workers, licensed professional counselors and all other behavioral health providers that use CPT codes).

• ValueOptions and all other third party insurers will need to clearly define codes for billing and payment practices utilizing the 2013 CPT code book.

2013 CPT Code Changes

• Effective, January 1, 2013 providers must convert to using the new codes for billing dates of service on or after January 1, 2013.

• Several CPT codes will remain the same (i.e. 90845, 90846, 90847, 90849, 90853).

• However, several other CPT codes are now retired (i.e. 90801-90829, 90862, 90857).

2013 CPT Code Changes• Additionally, psychiatrists and other physicians must use

Evaluation & Management (E/M) codes 992xx with an ‘add-on’ code if psychotherapy is performed.

• Initial Evaluation with medical services is now 90792; without medical services is now 90791.

• If initial evaluation code 90791 or 90792 is of “interactive complexity”, appropriate add-on code (i.e. 90785) must be used.

• Interactive code may be used with E/M only when add-on psychotherapy codes are used.

• 90839 refers to Psychotherapy for Patient in Crisis—60 minutes.

• +90840 refers to Crisis beyond 60 minutes, +90840 per each additional 30 minutes.

2013 CPT Code Changes, Medical Record Documentation &Provider Audits

• ValueOptions® and MHA have begun reviewing the billing patterns of the new E/M and crisis management CPT codes.

• If a review of claims since January 1, 2013 shows that an

agency is an outlier in the use of 99213, 99214, 99215, 90839, and +90840 code(s), for example, that agency may be subject to audit within the next 6 months.

• Providers must ensure that all billed services to the PMHS have the required documentation.

•  If the current billing pattern of the outlier code(s) starts to trend down, a previously identified agency may be removed from the potential audit list.

2013 CPT Code ChangesFor an exhaustive list of CPT code changes and resources for understanding these changes, refer to:

• American Academy of Child & Adolescent Psychiatryhttp://www.aacap.org/cs/business_of_practice/reimbursement_for_practitioners

American Psychiatric Association

http://www.psychiatry.org/practice

American Medical Association

http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/cpt/cpt-changes-workshops.page

Purchase the CPT® 2013 Professional Edition:

https://catalog.ama-assn.org/Catalog/?_requestid=614184

CMS Evaluation and Management Services Guide

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/eval_mgmt_serv_guide-ICN006764.pdf

The National Council for Behavioral Health Fact Sheet

http://www.thenationalcouncil.org/cs/national_council_live/upcoming_webinars#CPT

2013 CPT Code ChangesFor an exhaustive list of CPT code changes and resources for understanding these changes, refer to:

The ValueOptions 2013 CPT Code Changes Webinars http://www.valueoptions.com/providers/Files/pdfs/

Monthly_Provider_Webinar_Calendar.pdf

ValueOptions Spotlight Section:

http://www.valueoptions.com/providers/Providers.htm

ValueOptions Network Specific Page:

http://www.valueoptions.com/providers/Network.htm

Best Practice Review

Provide more detailed ASSESSMENTASSESSMENT information when discussing consumer’s presenting problem, symptoms, and behaviors exhibited or observed. Elaborate on the consumer’s moderate to severe areas of impairment.

Develop treatment plan GOALSGOALS that are consumer specific. Treatment plan reviews should reflect any goal modifications, updates, and consumer progress.

Best Practice Review

Create CONTACT NOTES CONTACT NOTES that in part, reflect the chief medical complaint/reason for the visit, consumer’s mental status, the delivery of services specified by the ITP, a brief description of the services provided, the plan for changes in treatment (if any), the consumer’s progress towards goals, and a legible signature with job title with credentials.

GROUP CONTACT NOTES GROUP CONTACT NOTES should reference consumer’s level of participation in group activities and reflect description of services and relatedness of the group to the consumer’s treatment goals.

Pending COMAR Changes

Below are proposed changes in the documentation language for individual providers: 

Progress notes for each face-to-face contact including:•Date of service;

•Reason for service;•Start time and end time;•Location;•Summary of interventions provided;

•Progress toward goals; and

•The treating mental health professional’s signature and date of service.

Thank You

Presented by…

Allison Smith-Holness, LCSW

Quality Management

Clinical Record/Provider Auditor

ValueOptions—Maryland

Office Phone: (410) 691-4039

Office Fax: (877) 381-5571

Email: Allison.smith-holness@valueoptions.com

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