Client No-Shows
True. You should use the "Other" checkbox in the progress note.
True or False: TM's can bill for IAP Lesson Plan's outside of session.
What is the maximum amount of time you should bill for writing an IAP (Individualized Action Plan).
60-75 minutes maximum for a lengthy and detailed IAP.
What does SI, SU and HI mean in clinical writing?
Suicidal Ideation (SI): 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): 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 (HI): Thoughts or fantasies about killing another person. It involves contemplating the act of murder.
Can you bill for email, text of faxing?
Technically, no. However, you can document in your progress note that you "communicated with _____ provider." For example, "Communicated with OP regarding IAP to provide information pertaining to therapeutic goals for IHT Service. Please do not write "faxed copy of IAP to OP provider."
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 the client's chart or documentation provided by caregivers.
True: You can bill for:
- HUB Documents
- Past discharge summaries from other therapeutic services/ higher levels of care
- IEP/school documents
- Neuropsych Assessment
- Physical health records from PCP
What is the maximum amount of time to bill for CANS completion?
60-75 minutes for a CANS with lots of detail in each section.
What is the abbreviation for DIAGNOSIS?
Dx.
Can you bill for writing a Safety Plan outside of session?
No. Safety plans are designed to be collaborative and should be billed for with families via parent consultation or in TM/Family sessions.
Can you bill for a "no show" if a client cancels before you have started driving to the session?
No.
What is the maximum amount of time you should bill for a Discharge Summary?
60 minutes for an extremely detailed discharge summary.
What is the maximum amount of time you should bill for writing a Compressive Assessment?
up to 3 hours for a VERY detailed CA.
What is the acronym for BEHAVIOR in clinical writing?
What individual(s) are in charge of decision making at a Care Plan Meeting (CPT)
Caregiver
What is the Member Outreach box used for in a progress note?
When a client physically no-shows a session.
Which of the following activities is not on the billable approved list for a TM session? (Nail Salon, 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 the consent forms are signed. Youth will have to pass the swim test to swim in the deep end. Staff should be in the pool or have feet in the pool sitting next to youth during swim.
Movie Theatre - Not considered therapeutic, as there is minimal talking and social skills are not being practiced during the movie. Not approved for sessions.
Can you bill for writing a Risk Assessment?
Yes.
What does "ADL" stand for?
Activities of Daily Living (ADLS) are basic self-care tasks required to live independently such as bathing, dressing, eating and toileting. They are often used to measure a person's functional ability. Difficulties performing them can indicate a need for support or assistance. A related category, (IADLS) include more complex tasks like managing finances, preparing meals and shopping.
What is the maximum amount of time you can bill for transporting a youth in the car?
There is technically no maximum amount of time. However, we should consider whether it is therapeutic if you are frequently in the car for the majority of the session during drop off/pick-up. Any CBHI service should consider if a main function of our role is becoming dedicated to transportation, we are not the appropriate service.
What location codes at the top of your progress notes are appropriate to use for the "member outreach" checkbox?
Home or School.
A client has asked to go over the border to NH to see a sand castle exhibit on a beach. Why would this activity be prohibited?
You cannot leave the state of MA with youth. We are only allowed to bill insurance for when youth is physically in the state of Massachusetts AND should not be crossing state lines with clients.
You are working on an IAP Review/Revision. You have JUST pushed out the target date. What are the appropriate "90 day Review Dates" that you are reflecting on progress for?
START DATE: 10/20/25
TARGET DATE: 04/20/25
10/20/25 - 01/20/25
What does "LOC" mean?
Level of Care: This references the different levels of clinical care:
HIGHEST TO LOWEST:
- Residential or Group home (long-term)
- Inpatient (inpx) (can be 2-4 weeks on average OR extended stay, which is longer)
- CBAT (shorter-term/ roughly 2 weeks)
- Partial Hospitalization - Outpatient, day programming for 6 hours per day. Can be in person or virtual.
- CSA
-IHT
- IHBS
- Outpatient
- ABA
- TM
Can you bill for filing a 51A?
Yes, you can bill for your call with the screener, but not for the written portion of the filing, as this is not documentation time that is covered under insurance specs.