Intervention and Collateral Services
Intervention and Collateral Services Copyright 2014 ValueOptions.® All rights reserved. Medical Necessity Copyright 2014 ValueOptions.® All rights reserved. 2 Medical Necessity of Services 227.000 Medical Necessity All RSPMI services must be medically necessary. Definition of Medical Necessity (Section IV-11) All Medicaid benefits are based upon medical necessity. A service is “medically necessary” if it is reasonably calculated to prevent, diagnose, correct, cure, alleviate or prevent the worsening of conditions that endanger life, cause suffering or pain, result in illness or injury, threaten to cause or aggravate a handicap or cause physical deformity or malfunction and if there is no other equally effective (although more conservative or less costly) course of treatment available or suitable for the beneficiary requesting the service. For this purpose, a “course of treatment” may include mere observation or (where appropriate) no treatment at all. The determination of medical necessity may be made by the Medical Director for the Medicaid Program or by the Medicaid Program Quality Improvement Organization (QIO). Coverage may be denied if a service is not medically necessary in accordance with the preceding criteria or is generally regarded by the medical profession as experimental inappropriate or ineffective using unless objective clinical evidence demonstrates circumstances making the service necessary. Copyright 2014 ValueOptions.® All rights reserved. 3 Documentation 226.200 Documentation The RSPMI provider must develop and maintain sufficient written documentation to support each medical or remedial therapy, service, activity or session for which Medicaid reimbursement is sought. This documentation, at a minimum, must consist of: A. Must be individualized to the beneficiary and specific to the services provided, duplicated notes are not allowed. B. The date and actual time the services were provided (Time frames may not overlap between services. All services must be outside the time frame of other services.), C. Name and credentials of the person, who provided the services, D. The setting in which the services were provided. For all settings other than the provider’s enrolled sites, the name and physical address of the place of service must be included, E. The relationship of the services to the treatment regimen described in the plan of care and F. Updates describing the patient’s progress and G. For services that require contact with anyone other than the beneficiary, evidence of conformance with HIPAA regulations, including presence in documentation of Specific Authorizations, is required. Copyright 2014 ValueOptions.® All rights reserved. 4 Documentation 226.200 Documentation (continued) Documentation must be legible and concise. The name and title of the person providing the service must reflect the appropriate professional level in accordance with the staffing requirements found in Section 213.000. Copyright 2014 ValueOptions.® All rights reserved. 5 Service Code Definitions Intervention Services Copyright 2014 ValueOptions.® All rights reserved. 6 Service Code Definition: Intervention-MHP SERVICE: Intervention. Mental Health Professional (Formerly Onsite and Off-Site Interventions, MHP) DEFINITION: Face-to-face medically necessary treatment activities provided to a beneficiary consisting of specific therapeutic interventions as prescribed on the master treatment plan to redirect a beneficiary from a psychiatric or behavioral regression or to improve the beneficiary’s progress toward specific goals(s) and outcomes. These activities may be either scheduled or unscheduled as the goal warrants. Services are to be congruent with the age, strengths, necessary accommodations for any disability, cultural framework of the beneficiary and his/her family. DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: PRIOR AUTHORIZATION REQUIRED ALLOWABLE PLACES OF SERVICE: Office (11); Beneficiary’s Home (12); School (03); Homeless Shelter (04); Assisted living Facility (13); Group Home (14); Other Locations (99) AGE GROUP(S): Adult, U21 Copyright 2014 ValueOptions.® All rights reserved. 8 7 Service Code Definition: Intervention-MHP DOCUMENTATION REQUIREMENTS (See Section 226.200 for additional requirements) • Start and stop times of the actual encounter with beneficiary • Date of service • Place of service, (If 99 is used, specific location and rationale for location must be included) • Client diagnosis necessitating intervention • Brief mental status and observation • Document how interventions used address goals and objectives from the master treatment plan • Beneficiary’s response to intervention that includes current progress or regression and prognosis • Any changes indicated for the master treatment plan, diagnosis, or medication(s) • Plan for next intervention, including any homework assignments • Staff signature/credentials/date of signature(s) Copyright 2014 ValueOptions.® All rights reserved. 8 Service Code Definition: Intervention-MHP Notes and Comments: Interventions of a type that could be performed by a paraprofessional may not be billed at a mental health professional rate unless the medical necessity for higher level of staff is clearly documented. Copyright 2014 ValueOptions.® All rights reserved. 9 Service Code Definition: Intervention-MHPP SERVICE: Intervention. Mental Health Paraprofessional (Formerly On-site and Off-Site Interventions, Mental Health Paraprofessional) DEFINITION: Face-to-face medically necessary treatment activities provided to a beneficiary consisting of specific therapeutic interventions prescribed on the master treatment plan, which are expected to accomplish a specific goal or objective listed on the master treatment plan. These activities may be either scheduled or unscheduled as the goal or objective warrants. Services are to be congruent with the age, strengths, necessary accommodations for any disability, cultural framework of the beneficiary and his/her family. DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 8 PRIOR AUTHORIZATION REQUIRED ALLOWABLE PLACES OF SERVICE: Office (11); Beneficiary’s Home (12); School (03); Homeless Shelter (04); Assisted living Facility (13); Group Home (14); Other Locations (99) AGE GROUP(S): Adult, U21 Copyright 2014 ValueOptions.® All rights reserved. 10 Service Code Definition: Intervention-MHPP DOCUMENTATION REQUIREMENTS (See Section 226.200 for additional requirements) • Date of service • Start and stop times of the actual encounter with beneficiary • Place of service, (If 99 is used, specific location and rationale for location must be included) • Client diagnosis necessitating intervention • Document how interventions used address goals and objectives from the master treatment plan • Beneficiary’s response to intervention that includes current progress or regression and prognosis • Plan for next intervention, including any homework assignments • Staff signature/credentials/date of signature(s) Copyright 2014 ValueOptions.® All rights reserved. 11 Service Code Definition: Intervention-MHPP Notes and Comments: Billing for this service does not include time spent transporting the beneficiary to a required service, nor does it include time spent waiting while a beneficiary attends a scheduled or unscheduled appointment. Supervision by a Mental Health Professional must be documented and addressed in personnel files in accordance with the agency’s policies, quality assurance procedures, personnel performance evaluations, reports of supervisors, or other equivalent documented method of supervision. Copyright 2014 ValueOptions.® All rights reserved. 12 Service Code Definitions MHP: Face-to-face medically necessary treatment activities provided to a beneficiary consisting of specific therapeutic interventions as prescribed on the master treatment plan to redirect a beneficiary from a psychiatric or behavioral regression or to improve the beneficiary’s progress toward specific goal(s) and outcomes. MHPP: Face-to-face medically necessary treatment activities provided to a beneficiary consisting of specific therapeutic interventions prescribed on the master treatment plan, which are expected to accomplish a specific goal or objective listed on the master treatment plan May be scheduled or unscheduled. Copyright 2014 ValueOptions.® All rights reserved. 13 Uncovered Services Examples of activities not covered: • Excluded Services (Section 223.00) RSPMI Manual • Educational services, telephone contacts, transportation, services found not to be medical necessary, • Waiting for a beneficiary while he/she has an appointment • Helping beneficiary pay bills • Reminding, monitoring, or assisting a beneficiary to take his/her medications • Helping beneficiary obtain benefits, services, or complete paperwork/applications (such as obtaining food stamps, housing, special education services, accessing food banks, voter registration). Copyright 2014 ValueOptions.® All rights reserved. 14 Covered Services Examples of covered services: • Monitoring/steering adherence to behavior modification plan • Assisting/directing a beneficiary in practicing psychological self-help skills (deep breathing, positive self-talk, focus prioritization, etc.) • Instructing/training an anxious beneficiary in use of progressive relaxation skills/techniques • Guiding, supporting implementation of cognitive behavioral plan Each service must be directed toward a ICD/DSM mental health diagnosis/symptoms and related to individualized objectives from the master treatment plan. Copyright 2014 ValueOptions.® All rights reserved. 15 Nurses and Interventions A Registered Nurse (RN) may bill for medically necessary professional (MHP) services if the requirements set forth in Section 213.000, 10 are met: Registered nurse (RN; licensed in the State of Arkansas) who has one (1) year supervised experience in a mental health setting (Services provided by the RN must be within the scope of practice specified by the RN’s licensure) Copyright 2014 ValueOptions.® All rights reserved. 16 Nurses and Interventions Nursing Services, such as the examples listed, are not billable under the RSPMI Codes: • Interventions provided by the RN prior to or following a physician visit on the same day must be mutually exclusive of the physician service. • Interventions that include obtaining vital signs, assessing drug interactions, disease symptomology, side effects of medications, mental status, referrals, triage, etc. are not separate and distinct services. Copyright 2014 ValueOptions.® All rights reserved. 17 Nurses and Interventions RNs may bill for medically necessary Intervention services by MHP. LPNs, certified as MHPPs, may bill for medically necessary Intervention services by MHPP. (See Section 213.100 for MHPP Training and Certification requirements) Copyright 2014 ValueOptions.® All rights reserved. 18 Documenting Interventions Copyright 2014 ValueOptions.® All rights reserved. 19 Disclaimer These examples are meant to be informational only and do not meet all service definition requirements for services indicated. Times, dates, goals and objectives, etc. are excluded for the purpose of brevity in examples. Copyright 2014 ValueOptions.® All rights reserved. 20 MHPP Intervention Service Code Definition? • “Alice is afraid to leave her house and hasn’t for several days. She complains that nobody comes to see her, so I visited with her and talked about her day and how she felt. I told her she needed to learn to relax. I told her that I would come back to see her tomorrow and she felt better.” • “Johnny isolates himself during school by sitting in a corner with his head down during play time. I encouraged him to get up and go play with the other kids and praised him for doing so.” What is the specific therapeutic intervention? Do these services require MHPP certification and training? How does this relate to the Master Treatment Plan? Copyright 2014 ValueOptions.® All rights reserved. 21 MHPP Intervention Intervention: Alice has panic disorder with agoraphobia, and often cannot leave the house. As part of Alice’s treatment, I helped her practice her progressive relaxation exercise recorded by her clinician, then had her rate her anxiety when talking about leaving the house. Response and Progress: She reports that since she has been using the recording daily as prompted by me, the length and severity of the anxiety are decreasing and she has been able to leave the house one time per week. Plan: Alice will continue to use the exercises as directed and will try to increase leaving the house to two times a week. Copyright 2014 ValueOptions.® All rights reserved. 22 MHPP Intervention Intervention: Johnny is shy and isolates due to depression after years of neglect and abuse. During recess, we talked about a book he had read about friendship and then practiced asking a boy to play catch with him. Response and Progress: He was able to role play with me, but reported being very afraid of other kids saying “no” when he asked, then became tearful. Plan: Will continue to role play with him and notify clinician of ongoing sadness and isolation for possible changes to MTP. Copyright 2014 ValueOptions.® All rights reserved. 23 MHP Intervention Service Code Definition? • Sue is disruptive in the classroom and does not follow directions often refusing to do as asked by any school personnel. I reminded her that she was to do what she was asked to do. • Jane goes on spending sprees and neglects to pay her bills. I helped her write her bills during today’s weekly home visit. What is the specific therapeutic intervention? How does this relate to the Master Treatment Plan? Do these services require MHP licensure? Copyright 2014 ValueOptions.® All rights reserved. 24 MHP Intervention Intervention: Introduced Sue to a behavioral plan as part of her treatment for ODD that rewards her with stars for compliance with instructions. Taught Sue the difference between positive and negative consequences. Practiced compliance with instructions, starting with requests for her to do things she found rewarding and changing to those things that she liked to do the least. Response and Progress: She was able to follow requests 1 out of 5 times and to understand the difference between positive and negative consequences. Plan: Will continue to reinforce behaviors as part of behavioral plan and introduce to MHPP, parents, and school staff. Copyright 2014 ValueOptions.® All rights reserved. 25 MHP Intervention Intervention: Jane goes on spending sprees when in a manic state and fails to manage her resources. As per her treatment plan, assisted Jane with developing an illness management plan and advanced directive so when she becomes manic, her support system puts her plan into action to protect her and her finances. Response and Progress: Jane was able to identify people she trusts and are responsible, thus completing the first step in developing an advanced directive. Plan: Jane will talk to identified people to determine if they are willing to help with her illness management plan and report back during next session. Copyright 2014 ValueOptions.® All rights reserved. 26 Collateral Services Copyright 2014 ValueOptions.® All rights reserved. 27 MHP and MHPP Collaterals Role of the MHP and MHPP in Collaterals When it is necessary to obtain or share from collateral sources, medically necessary information relevant to the beneficiary’s assessment, treatment plan (treatment plan update) or rehabilitation, it is the treatment team’s responsibility to determine the specific essential information to be collected, as well as the timelines and frequency. When medically necessary, the MHP may benefit from services of a Mental Health Paraprofessional (MHPP) to obtain or share the information in clinical and non-clinical settings such as home or community. Copyright 2014 ValueOptions.® All rights reserved. 28 Collateral Services-MHP SERVICE: Collateral Intervention. Mental Health Professional DEFINITION: Face-to-face contact by a mental health professional with caregivers, family members, other community-based service providers or other Participants on behalf of and with the expressed written consent of an identified beneficiary in order to obtain or share relevant information necessary to the enrolled beneficiary’s assessment, master treatment plan, and/or rehabilitation. The identified beneficiary does not have to be present for this service. Services are to be congruent with the age, strengths, necessary accommodations for any disability, cultural framework of the beneficiary and his/her family. DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 4 PRIOR AUTHORIZATION REQUIRED ALLOWABLE PLACES OF SERVICE: Office (11); Patient’s Home (12); School (03); Homeless Shelter (04); Assisted living Facility (13); Group Home (14); Other Locations (99) AGE GROUP(S): Adult, U21 Copyright 2014 ValueOptions.® All rights reserved. 29 Collateral Services-MHP DOCUMENTATION REQUIREMENTS (See Section 226.200 for additional requirements) • Date of service • Names and relationship to the beneficiary of all persons involved • Start and stop times of actual encounter with collateral contact • Place of Service ( if 99 is used, specific location and rationale for location must be included) • Client diagnosis necessitating intervention • Document how interventions used address goals and objectives from the master treatment plan • Information gained from collateral contact and how it relates to master treatment plan objectives • Impact of information received/given on the beneficiary’s treatment • Any changes indicated for the master treatment plan, diagnosis, and medication(s) • Plan for next contact, if any • Staff signature/credentials/Date of signature Copyright 2014 ValueOptions.® All rights reserved. 30 Collateral Services-MHP Notes and Comments: • The collateral intervention must be identified on the master treatment plan as a medically necessary service. Medicaid WILL NOT pay for incidental or happenstance meetings with individuals. For example, a chance meeting with a beneficiary’s adult daughter at the corner store which results in a conversation regarding the well-being of the beneficiary may not be billed as a collateral contact. • Billing for Interventions performed by a mental health professional must warrant the need for the higher level of staff licensure. Professional interventions of a type that could be provided by a paraprofessional will require documentation of the reason it was needed. • Contact between individuals in the employment of RSPMI agencies or facilities are not a billable collateral intervention Copyright 2014 ValueOptions.® All rights reserved. 31 Collateral Services-MHPP SERVICE: Collateral Intervention. Mental Health Paraprofessional DEFINITION: Face-to-face contact by a mental health paraprofessional with caregivers, family members, other community-based service providers or other Participants on behalf of and with the expressed written consent of an identified beneficiary in order to obtain or share relevant information necessary to the enrolled beneficiary’s assessment, master treatment plan, and/or rehabilitation. Services are to be congruent with the age, strengths, necessary accommodations for any disability, cultural framework of the beneficiary and his/her family. The identified beneficiary does not have to be present for this service. DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 4 PRIOR AUTHORIZATION REQUIRED ALLOWABLE PLACES OF SERVICE: Office (11); Patient’s Home (12); School (03); Homeless Shelter (04); Assisted living Facility (13); Group Home (14); Other Locations (99) AGE GROUP(S): Adult, U21 Copyright 2014 ValueOptions.® All rights reserved. 32 Collateral Services-MHPP DOCUMENTATION REQUIREMENTS (See Section 226.200 for additional requirements) • Date of service • Names and relationship to the beneficiary of all persons involved • Start and stop times of actual encounter with collateral contact • Place of Service ( if 99 is used, specific location and rationale for location must be included) • Client diagnosis necessitating intervention • Document how interventions used address goals and objectives from the master treatment plan • Information gained from collateral contact and how it relates to master treatment plan objectives • Impact of information received/given on the beneficiary’s treatment • Any changes indicated for the master treatment plan which must be documented and communicated to the supervising MHP for consideration • Plan for next contact, if any • Staff signature/credentials/Date of signature Copyright 2014 ValueOptions.® All rights reserved. 33 Collateral Services-MHPP Notes and Comments: • Supervision by a Mental Health Professional must be documented in personnel files and addressed in accordance of agency’s policies, quality assurance procedures, personnel performance evaluations, reports of supervisors, or other equivalent documented method of supervision. • The collateral intervention must be identified on the master treatment plan as a medically necessary service. Medicaid WILL NOT pay for incidental or happenstance meetings with individuals. For example, a chance meeting with a beneficiary’s adult daughter at the corner store which results in a conversation regarding the well-being of the beneficiary may not be billed as a collateral contact. • Contacts between individuals in the employment of RSPMI agencies or facilities are not a billable collateral intervention. Copyright 2014 ValueOptions.® All rights reserved. 34 Collateral Services MHP Collateral: Professional assessment requires the licensure and skills of a professional and is generally done for the purpose of developing or modifying a treatment plan. MHPP Collateral: Obtaining information is the assignment of a paraprofessional to monitor and/or make inquires concerning an individual’s progress in treatment for the purpose of reporting back to the professional. Copyright 2014 ValueOptions.® All rights reserved. 35 Collateral Services Examples: Uncovered Services Incidental or happenstance meetings Mediating with creditors Serving as liaison or agent for social service agencies Making appointments for beneficiary Making phone calls on behalf of the beneficiary to any agency or individual including family members. Copyright 2014 ValueOptions.® All rights reserved. 36 Collateral Services Examples: Covered Services • Conferring with family members concerning beneficiary’s behavior at home • Conferring with landlord to determine whether beneficiary’s symptomatic behavior has decreased. • Conferring with a client’s teacher to collect information concerning client’s symptomatic behavior in the school setting Copyright 2014 ValueOptions.® All rights reserved. 37 Documenting Collateral Services Copyright 2014 ValueOptions.® All rights reserved. 38 Disclaimer These examples are meant to be informational only and do not meet all service definition requirements for services indicated. Times, dates, goals and objectives, etc. are excluded for the purpose of brevity in examples. Copyright 2014 ValueOptions.® All rights reserved. 39 Documenting Collateral Services What information is being obtained and how is it relevant to treatment or treatment planning? Please Note: Before conducting a collateral service, a release of information is required from all adult beneficiaries and from the parent/s or legal guardian/s for the beneficiaries under the age of 18 or those 18 and older with a legal guardian. Copyright 2014 ValueOptions.® All rights reserved. 40 MHP Collateral Intervention Service Code Definition? Matt cannot be relied on to obtain and take his medication. I saw his wife in town and she said she did not know if he was taking his medication. Does this service require MHP licensure? What makes this a happenstance meeting? What impact will this information have on treatment? What is the plan for next contact? Copyright 2014 ValueOptions.® All rights reserved. 41 MHP Collateral Intervention Matt has not been attending his medication appointments, and he is requesting MD call in his medications. MHP met with his wife to see if he had picked up his medications. His wife reported “Matt paid for and picked up his medicines and threw them in the trash on the way out of the pharmacy.” She also reported “He thinks people are trying to control his mind.” MHP reviewed with wife signs of escalation and reviewed crisis plan. MHP will report this information to the physician and modify treatment plan accordingly. Copyright 2014 ValueOptions.® All rights reserved. 42 MHPP Collateral Intervention Service Code Definition? Katie’s teacher stopped me in the hall at Katie’s school today and asked to talk with me about Katie. She said Katie is “still crying in class” and remains disliked by peers. She also wanted to see if I had time to sit with Katie in the library today, because they are short handed during library time and Katie needs extra attention. How is this information relevant to client’s MTP? How will this information impact client’s treatment? What is the plan for next contact? Copyright 2014 ValueOptions.® All rights reserved. 43 MHPP Collateral Intervention Meet with Katie’s teacher at school. She reported, “Katie has started hitting peers in the face with her fist and yelling, “I hate you!”” MHPP will document this information and contact Katie’s therapist to inform her of the new information before close of business today. Copyright 2014 ValueOptions.® All rights reserved. 44 Documenting Collateral Services Information obtained or shared in collateral contacts must be medically necessary (necessary to the enrolled beneficiary’s assessment, master treatment plan, and/or rehabilitation). Ask the following questions: Is it medically necessary for an MHP and an MHPP to obtain or share the same information with or from the same collateral source in the same day? Is it medically necessary for an MHP or an MHPP to obtain or share information that is already known by the treatment team? Copyright 2014 ValueOptions.® All rights reserved. 45 Exclusions for RSPMI 223.000 Exclusions for all RSPMI Services Services not covered under the RSPMI Program include, but are not limited to: Room and board residential costs; Educational services; Telephone contacts with patient or collateral; Transportation services, including time spent transporting a beneficiary for services (reimbursement for other RSPMI services is not allowed for the period of time the Medicaid beneficiary is in transport); Services to individuals with developmental disabilities that are nonpsychiatric in nature, except for testing purposes; RSPMI services which are found not to be medically necessary; RSPMI services provided to nursing home and ICF/MR residents other than those specified in Section 252.150. Copyright 2014 ValueOptions.® All rights reserved. 46 Questions? Copyright 2014 ValueOptions.® All rights reserved. 47 Please watch for a survey following this webinar. We appreciate your feedback. Copyright 2014 ValueOptions.® All rights reserved. 48
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