Service Rules
How many hours can you bill for an adolescent in a week?
5 to 7 hours a week
What is the service code for Skills Building with adults?
H2014
Can I use therapeutic verbiage within my B.I.R.P. note? (ex; CBT, play-therapy, therapeutic methods, etc.)
No.
If a parent calls and states " We will need to move our scheduled time for Kimmy's session to 8:45pm." What should you do?
Let the Parent know that service hours end at 8:00pm however we can reschedule for another day.
Using the wrong service code for the intervention provided is called this.
Miscoding
How long do you have to submit your note after servicing a client?
Notes are due within 24 hours after session
What code do you use for a Case Management note for an adolescent?
T1017
What should be included in the (P)lan section of the BIRP note?
Mental Health Homework
Your in the middle of a session when your client falls and sprain their ankle. What should you do?
Call your supervisor immediately and complete an incident report form. Inform all necessary parties.
Every progress note should include the intervention, response, and this.
Client’s progress toward goals
What is the latest time you can provide services?
Services for all clients should not exceed 8pm.
What code do you use for Skills Training with an adolescents?
H2014
What section should the treatment plan progress be identified in, within the BIRP note.
(R)esponse.
If your client states, "This week has been so hectic can we just do a virtual call." What should you do?
All virtual calls must be approved by your supervisor.
Billing two incompatible service codes at the same time may result in this audit finding.
Duplicate billing
Can I drive my client to the park or other outings?
No.
What code do you use for Case Management for adults
T1017
How do I make an edit to my note?
By submitting an addendum section and forwarding it back to the reviewer.
This is one of the biggest red flags during an audit: billing for services not rendered.
fraudulent billing
Backdating notes without indicating the actual completion date is considered this violation.
Falsification of records
On the weekends when does your notes have to be submitted?
Sessions completed on the weekends must be in the system by 11:59pm Sunday Night.
What code do you use for Medication Management?
H0034
How many characters should the behavior section of a 3 hour note be?
1800-2100 characters
Supervisors often monitor this to ensure documentation compliance.
Note timeliness
A QMHP completes 12 progress notes three weeks late, all with identical wording and missing client responses. Name at least TWO audit concerns.
Late documentation
Cloned notes
Missing individualized interventions
Missing client response/progress