General 1
How often should the Problem List be provided?
It should be updated on ongoing basis, adding or removing problems when there is a relevant change to clients condition or when new problems are identified.
Which activity should be selected if therapist or case manager linked client/caregiver to educational resources?
TCM (or ICC)
** must document care plan in Next Steps of note**
If you were part of a CFT meeting, which activity should be selected?
Intensive Care Coordination (ICC)
Not to be confused with Coordination of Care.
Where do I put my minutes (in the appointment details of the note) for Record Review?
A. Session Duration
B. Documentation Time
C. Other Time
D. Travel
C. Other Time
If Therapist and Case Manager were present for a session, and CM provided interpretation during the session, who would be able to select the Oral Interpretation add-on code?
Therapist.
*The provider RECEIVING interpretation services may select the add-on code.
Which assessment does the Immediate Same Day Service Assessment replace?
Immediate Same Day Service Assessment can be completed in place of the Full IA and ICARE.
The Full IA and ICARE are still available in Exym for use.
What activity should be selected if the therapist or case manager met with client's teacher to provide skills/psychoeducation to better support client in the classroom?
Rehabilitation
Which activity should be selected if provider called mom to check in over the phone to assess client’s symptoms/behaviors/status (e.g. check in with client or significant support person to see if they are successfully utilizing skills learned).
Telephone Assessment and Management Service
*Telephone service only
Which Places of Service do I need to manually enter a specific address?
Group home, Shelter, School (if school address is not populating), Other unlisted facility
TRUE OR FALSE.
Case Managers, Parent Partners, Students, etc. may only select Oral interpretation/Sign language add-on code?
True.
If you are meeting with caregiver/client for the sole purpose of completing (e.g. CANS/Needs Eval Tool, depression inventory, ADHD disorder scale) as a stand alone service, which activity should be selected for a therapist?
Which activity should be selected for a case manager, parent partner, etc.?
Brief Emotional/Behavioral Assessment (96127) if therapist.
Comprehensive Multidisciplinary Assessment (H2000) if case manager, parent partner, etc.
If a Wellnest provider is reaching out to coordinate Client care with Regional Center worker, which activity would you select?
Coordination of Care
What would be your place of service if you are having a Plan Development with Wellnest staff (with direct client care)?
Office
*for all consultations between staff members, even if virtual or telephone.
When should the non-contact box be selected?
Any session where you visually cannot see the client's/caregiver face.
If I provided a service in another language, can the Oral Interpret / Sign Language add-on code be selected?
No.
*The provider RECEIVING interpretation services may select the add-on code.
Needs Evaluation Tool is completed for Clients 21 and over. How often should this be completed?
Yearly
TRUE OR FALSE.
Multiple services can be combined in one note (ex: providing parenting skills to mom and exploring resources/linkages in the same service contact).
True. Two distinct services can now be combined if they occurred in they occurred in the same service contact.
If you are providing Rehabilitation services and the Client has been authorized for IHBS, what activity would you select?
IHBS- Rehabilitation
If I have a combined service at 12:30pm and another another at 1pm, what should be the appointment time for the note?
12:30pm
The earliest appointment time.
Which add-on code may be selected when a communication barrier occurs that is atypical of my normal session with this client (i.e. Client has difficulty communicating in this session due to psychotic symptoms)?
Interactive Complexity
If a Case Manager writes a regular plan development in the morning and then writes a multiple provider plan development for the same Client in the same day. Is this considered a duplicate service?
Yes.
If the same provider delivers 2 services to the same client on the same day in 2 or more separate encounters for the same service, 1 note should be written.
Which activity should be selected if:
Session was with Mother to provide psycho-education/skills (30 min) and linkage to financial resources (5 min).
Rehabilitation
True or False.
If a case is being transferred and new provider has not had billable contact with Client or Caregiver, Plan Development session cannot be billed by new provider.
True.
*Only those with direct client care can claim PD
When should I mark a note No Charge?
When the session duration falls under the minimum time for that service.
*See Activity specific minimums on the Cal Aim staff guides on the intranet
Can you select Oral Interpretation Add on code if you already selected Interactive Complexity?
No, we are unable to select both these add on codes for 1 note.