Comprehensive Assessment
How many days do you have to complete the Comp Assessment from date of intake?
2 business days
What type of note do you use when you complete a DHS report 2 months into treatment?
Case Management
What does SMART stand for?
Specific, Measurable, Achievable, Relevant, Time Based
What form do you need to have signed in order to talk to someone else about a client's progress?
Release of Information
Name the 3 APS teams
Northeast, Northwest, South
What's the difference between these codes? Mental Health Assessment (H0031) and Intake (90791)
Diagnosis and MSE must be completed for 90791
What type of note is not billable?
Note to Chart
When must the care plan be completed by from the date of Intake?
On or before the 1st therapy session and within 14 days.
12yo
When and where are team meetings?
Th 3-4:30pm Leversee
How often does the Comprehensive Assessment need to be reviewed?
every 6 months
What is the name of the code that you can use when a client has present challenges such as: difficulty engaging in session, is developmentally disabled, or significantly processing trauma?
Add on code Interactive Complexity
When does a care plan review need to be completed?
Every 6 months or change in primary diagnosis
Outside from your teammates, where do you find answers to coding questions?
MyWeb, F: drive, QI Coding and clinical documentation hours on Tuesdays
Name the 3 intake coordinators
Amanda, Erin, Diana
What is medical necessity?
Service is necessary for treatment of mental health disorder; service is the least restrictive and will address symptoms if dx; stopping service will increase sx or reduce level of functioning
DAILY DOUBLE!
What change was made for individual therapy sessions that last 90 minutes?
Can bill for 2 45-minute sessions
Who has to sign the Care Plan?
Client, therapist, parent/guardian if 11yo or younger
(med provider if applicable; supervisor for unlicensed therapists)
What are the 5 documentation components of the "Golden Thread" concept?
Intake/assessment, care plan, progress notes, care plan review, discharge
Name the 3 Integrated Care Therapists
Michelle, Michal, Alondra
When you review the comprehensive assessment at the required review period, and client reports changes, what would you do?
complete a comp assessment update
Name 2 types of billable notes that do not require a care plan in a Client's chart.
Intake (90791), Mental Health Assessment (H0031), Behavioral Health Outreach (H0023), Behavioral Health Screening (H0002), Crisis Intervention (H2011)
Would this be an intervention or objective?
"Therapist will meet with client weekly to enhance client's coping tools and ability to implement them when needed"
Intervention
DAILY DOUBLE! What are 5 of the 7 note audit questions
reason for services, intervention provided, response to intervention, plan, progress toward objective, individualized, is correct code used?
What are the 6 core values?