Who's Who
What are the 3 main types of billable therapeutic sessions that are provided by the therapist?
Individual, collateral and family therapy sessions. Other non-billable services include outreach calls to schedule sessions and/or coordinate care with collaterals, documented as a CM note.
33 Min session, held in person, with 29 year old client.
R30. The session is expected to last 30 min, but is billable from 16-37 min.
How often should clients be scheduled for therapy sessions?
Once per week, or as clinically indicated. Any recommended changes in frequency should be discussed in clinical supervision.
13 year old client got into a physical altercation with sibling.
Not reportable. This incident type would only be reportable if it happened on site.
When should progress notes be completed?
No later than 24-48 hours after the date of service., and ideally concurrently! Use your IMA To-do list and weekly reports to keep track of your work. Notes are considered late after 4 days from the service.
What is the role of an NYPCC Case Manager?
Case Managers assign clients to therapists (schedule ADM/VAM). They also receive client referrals, schedule intake appointments, outreach ADM NSs, and assist with referrals to other providers when needed.
42 minute video session, held with 13 year old client.
V45. The session is expected to last 45 min, but is billable after 38+ minutes.
What is the minimum frequency of collateral participation in treatment?
At least one collateral session per month for all clients under the age of 18. One exception is that a child who is a parent is treated as an adult.
Client takes 2 Tylenol because she "wanted to just sleep and not be alive."
Reportable as a suicide attempt. Despite the lack of apparent harm or lethality, the action taken while having S/I constitutes an attempt.
What are the 4 primary IMA write templates therapists use?
Individual, Collateral, family, and No-show are the primary templates used, but there are also templates for case management and crisis notes.
Who is/are your clinic's director(s)?
Trainer to confirm the correct answer! Review the current Program Director and Assistant Program Director(s) for each clinic location of the new therapist cohort.
Video Admission session is also known as ...
VAM. Remember that this is not a billable code and serves only as a place holder in your calendar for an initial session scheduled for a client awaiting admission.
After a missed session, what steps should be taken?
For ADM/VAM, mark the appointment as "No-show" in IMA, then the Engagement team will provide outreach.
For clients already admitted to the clinic, follow the no-show procedures:
1. Outreach the client via phone within the first 10 min of the scheduled time in an attempt to start the session. If the client does not respond, leave a message to reschedule.
2. If the client does not respond after 48 hours, provide additional phone outreach and send a Missed Session letter, then consult with your supervisor for next steps. *If high risk, outreach within 24 hours and consult with Supervisor as needed.
Client reports suicidal ideation, with plan to ingest pills over the weekend.
Not reportable. The plan is concerning and 911/EMS referral is warranted, but an attempt has not yet been made so an incident report is not needed.
What is the best practice for timely documentation?
Concurrent/Collaborative Documentation. We have a training on this!
What is the difference between a Clinical Supervisor and an NYPCC Training Specialist?
Clinical supervisors oversee the clinical aspects of your work with clients, conduct regular supervision meetings and provide caseload oversight.
Training specialists conduct Onboarding Trainings, review clinical documentation during the initial training period, and assist with procedural questions regarding IMA and clinical documentation.
Collateral participates in 5 minutes of the video session with the child, and the remaining 25 min of the session are held with the 5 year old client alone.
V30. So long as the client was present for the full duration it can be billed. Be sure to include the collateral's name, relationship and participation in your session note.
What is the easiest way to ensure that clients are scheduled consistently?
Schedule the client's next appointment at the end of each session. If the client misses a session provide outreach and document your outreach attempts in a CM note.
12 year old client discloses that she's been cutting her arm, wrists and legs with razors with no suicidal intent.
Not reportable. Ask the client to show or describe the cuts in order to assess the need for medical attention. Inform your supervisor, collaborate with collateral, update the safety plan and consider possible referral to psych ER if clinically indicated.
Is VAM a billable service that I can write a progress note for?
No! A VAM is not a billable activity code so DO NOT WRITE YOUR NOTE until the client is admitted via Clerical Request form and your calendar appointment is converted to a V30 and checked-in, after which you will be able to document the billable progress note in IMA and save unsigned as a V30/V45/VCO.
How do you refer a client to the Care Coordination program? And what services do they offer?
The LINK > Clinical Resources > Care Coordination Referral (complete online form)
Care Coordinators assist clients with practical needs and referrals, such as housing, medical and public assistance.
You are unable to keep a scheduled session due to a conflict with an upcoming training.
CM and CAP! This session is being cancelled by the practitioner (that's you), so you can call the client to reschedule and write a CM note for the outreach call. Then, for the date of the intended session, you can use the CAP code for the note connected to the IMA calendar appointment.
Show us how to schedule recurrent lunch or supervision appointments.
Calendar > Copy > Add member > Include all dates > Copy
Remember that client appointments must be scheduled and verbally confirmed by the client each week, so the copy feature should not be used.
15 year old client is missing, as reported by the guardian, and they were last seen by you for an in-person therapy session at the NYPCC clinic.
Reportable. Any significant incidents that happen on-site require an incident report, including a client who is missing. Review the Incident Report form and training materials for guidance.
If you do not check in your client, you can not _____.
Write the progress note. Remember to update the status of all scheduled appointments daily as either checked-in or no-show.