Client No-Shows
True or False: You can bill for waiting for a no-show Telehealth session.
True. You should use the "Other" checkbox in the progress note.
True or False: TM's can bill for IAP Lesson Plans outside of session.
False. IAP Lesson Plans are encouraged to be billed for with caregivers during a consultation, or with the HUB on a consultation call.
What does SI, SU, and HI mean in clinical writing?
Suicidal ideation - This is the desire to be dead or to die, but without forming a specific plan to do so. Examples include wishing to go to sleep and never wake up, or thinking that others would be better off without you.
Substance Use: (SU) is a chronic mental health condition characterized by a pattern of compulsive substance use that leads to significant problems in a person's life.
Homicidal Ideation: Thoughts or fantasies about killing another person. It involves contemplating the act of murder, including
Can you bill for email, text or faxing a collateral?
For example:
You cannot explicitly note something like, "faxed copy of IAP to OP provider."
You can: "Communicated with OP regarding IAP to provide information pertaining to therapeutic goals for IHT service."
How long can you bill for waiting for a client who has no-showed an appointment?
Up to 30 minutes.
True or false: You can bill to read documentation in client's chart or documentation provided by caregivers.
- HUB Documents
- Past discharge summaries from other therapeutic services/higher levels of care
-IEP/ school documents
-Neuropsych
-Physical/health records from PCP
What is the maximum amount of time to bill for CANS completion?
Roughly 60-75 minutes with lots of detail in each section.
What is the abbreviation for diagnosis?
Dx.
Can you bill for writing a Safety Plan independently?
No. Safety plans are designed to be collaborative and should be billed for with families via parent consultation or family sessions.
What is the Member Outreach Box used for in a Progress Note?
When a client physically no-shows a session.
What is the maximum amount of time to bill for a discharge summary?
Up to roughly 40 minutes.
Up to 3 hrs for a VERY detailed CA.
What is the acronym for behavior in clinical writing?
Bx
What is the Member Outreach Box used for in a Progress Note?
To bill for when a client physically no-shows an in-person session.
Which of the following activities is not on the billable approved list for a TM session? (Nail salon, going to a movie theatre, swimming at YMCA).
Nail salon - Approved IF hygiene is related to a specific goal, and youth brings their own money to pay for service
YMCA - As long as consent forms are signed. Youth will have to pass swim test to swim in the deep end. Staff should be in the pool or have feet in the pool next to youth during swim.
Movie theatre - Not therapeutic - no talking or social skills practiced. Not approved for sessions.
What are the appropriate "90 day review dates" for the following IAP Review example: Start Date: 10/20/25, Target Date: 01/20/25 (just got pushed out to this date in this document, Current Date of reviewing document: 10/19/25
08/20/25-10/20/25
What does "ADL" stand for in clinical writing?
Activities of Daily Living -Activities of daily living (ADLs) are basic self-care tasks required to live independently, such as bathing, dressing, eating, and using the toilet. They are often used to measure a person's functional ability, and difficulties performing them can indicate a need for support or assistance. A related category, instrumental activities of daily living (IADLs), includes more complex tasks like managing finances, preparing meals, and shopping.
What is the maximum amount of time you can bill for transporting a client in your car?
There is technically no maximum amount of time. However, we should consider whether this is therapeutic and how much time you are spending with the client.
What location codes at the top of your progress notes are appropriate to use for member outreach?
Home or School.
What does "LOC" mean?
Level of care - This references the different levels of clinical care:
HIGHEST to LOWEST example:
- Inpatient (short-term) AKA IPLOC
- CBAT (short-term)
- Residential or Group Home (longer-term)
- CSA - Community Service Agency
- IHT - In-Home Family Therapy
- Outpatient Therapy
- In-Home Behavioral Services
- ABA - Applied Behavioral Analysis
- Therapeutic Mentoring
Can you bill for filing a 51A?
Yes - You can bill for the phone call with the screener to DCF. You cannot bill for the written portion of the filing.