Treatment Planning
True or false: A treatment planning conversation/session needs to be 8 minutes long in order to bill the H0032 code.
True. However, if you have more than one treatment planning session in a day and they add up to 8 minutes+, bill both. The lines will get rolled into one billable service by the business office.
Example: Conversation with teacher for 3 minutes about ITP at 12PM, and then a Phone call with caregiver for 6 minutes about ITP at 1 PM. Bill 12-12:03 w/ General Progress Note and 1-1:06 w/ General Progress Note.
True!
True or false: A caregiver needs to engage in the activities with you and the client in order to bill for family skills.
False! Great ways to encourage caregiver's knowledge of and use of skills to support client's functioning and progress include:
1. Staying within earshot of caregiver. Draw caregiver in with your enthusiasm for the kiddo, such as "That's awesome! Mom, come see what Marianne just did! Can you show mom? Mom, what do you think of that?” (eliciting caregiver praise for child)
2. At the beginning of session, have a moment with caregiver to check in and ask if there are any areas that would be helpful to address with client today. Draw discussion back to the identified objectives to stay on track. At end of session, check in with them again explaining what you did and how client did. Ask if they can help support that skill over the next week. (Billing will vary depending on how caregiver was involved through session - might need to be a separate family skills and individual skills billing)
True or false: You can bill family skills without client present (caregiver-only) when you have a phone check-in with a caregiver that lasts at least 8 minutes.
True and it depends on the content of the conversation and its reflection in the note.
True or false:
During family therapy, a therapist can bill family therapy and a skills worker can bill skills if there are at least two child clients in session.
Depends on how many family members are present! If there are 2 clients and 3 family members present (e.g., three siblings; siblings and a parent), then one staff can bill family and the other can bill individual.
If there are 4 family members present, and at least 2 of them are clients, there can be 2 family billings. Example: Family includes Bob (client), Bill (client), Brenda (non-client sibling), and Dad. Session is held with all family members and two staff. Staff 1 can bill family w/ Bob and Brenda. Staff 2 can bill family w/ Bill and Dad.
BUT - this also needs to be clinically appropriate and make sense according to who was involved in session.
Ensure that each staff bills on a separate client and be clear about the role of the skills worker in the family therapy session and who was present.
True or false: You cannot bill the H0032 code twice in one day for the same client.
False! It's billed by calendar year. Each client gets 24 sessions/year. If you need more treatment planning sessions, contact Shannon.
True or false: Sibling and client need to stay together the entire session in order to bill the session as family skills.
False! The majority of session should include the siblings present together.
Be sure to dictate on how you worked with both client and sibling to address client's objectives as written in the ITP.
Tip - most every time, this will include providing an opportunity to practice that skill with their sibling in their natural home environment.
You meet your client at home, have a 15-20 minute conversation with client and caregiver about how she's been doing in skills (what she's learned, whether she's been practicing at home), and then you bring client in the community for the remaining 1.5 hours. How should this be billed?
Family skills for the first 15-20 minutes (use your best judgement to estimate).
Individual skills for the remainder.
Two separate progress notes.
What needs to occur and what needs to be documented to bill a phone call with a caregiver as Family Skills w/out Client (Caregiver-Only)?
You need to be purposeful to address the client's progress and teach, model, coach, or praise/positively reinforce with the caregiver strategies they can use to address client's objective.
Must document one of those strategies toward the objective and caregiver's response to it.
Time spent working with caregiver must reflect time billed.
Ensure you have consent for telehealth (billed as POS air/ambulance).
True or false: You can bill family skills for an ARMHS client.
False.
You call a caregiver to check in about the unsigned treatment plan on the portal and spend time problem solving caregiver's issues getting it signed and learning about/giving suggested strategies for new behaviors that have arisen. Can you bill the treatment planning code?
Yes. Here's an example:
The goal for this session was to consult with Max's mother regarding meeting to implement the treatment plan and signing the treatment plan in order to provide services.
Staff called Max's mother and inquired about signing the treatment plan and updates in functioning. She reported barriers to using the client portal and provided verbal consent for the plan and new challenges with his behavior including defiance (i.e., responding "No" and questioning parents regarding requests). Staff suggested this may be developmentally expected and offered strategies. Max's mother reported she may try them and requested that treatment include focusing on the new challenges. Staff agreed that addressing the behaviors falls within the goal of improving social skills/relationships and emotion regulation.
Staff will follow up regarding ability to sign the plan. Verbal consent received and staff will move forward providing services within this plan.
Your client lives with his mom. Mom's parents are his secondary caregivers - they are often in the home, even though they don't live there. Mom requests that grandparents are involved in services and would like you to have sessions in the home with client and grandparents while she is at work. Can you bill family for these sessions?
Yes! A family member is defined however the family defines it. This can include close friends, aunts/uncles, cousins, grandparents, etc.
You have a pair of siblings as clients. Dad prefers that sessions occur twice a week at the same time, meeting with siblings together. How should this be billed?
It depends! If siblings want their own time 1:1 and do not wish to interact together, you could meet in an area where they are both present but separate to allow for confidential time, and bill two individual sessions/day. This would be something to address with caregiver if it continues (and with clients).
Or, more likely, you bill family and rotate each session, billing one session under first sibling and next session under second sibling, or two billings and notes each session. Time cannot overlap.
You text a caregiver to confirm client's individual telehealth session for today. She informs you that client is ill and won't be in session.
What would be an appropriate way to still provide needed clinical service?
Ask if you can call caregiver briefly to check in. Prepare a list of questions and talking points related to client's symptoms/functioning/progress and ITP objectives; what's been working well and what hasn't been working well; and ensuring to praise caregiver.
If in the phone call discussion you teach, model, coach, or praise caregiver to encourage use of client's skills as identified in the ITP, you can bill as H2014 family skills - caregiver only
True or false:
You can bill family therapy for an adult outpatient client.
True! This could be helpful in situations such as:
1. An emerging adult (e.g., 18-23) year old client is working on advocating for themselves and expressing emotions. They have conflict with their parents/siblings, and after practicing and role playing with them, you schedule a family session for the client to communicate with family using those skills in a safe setting, and with your support.
2. An adult struggles to regulate their emotions during parenting. You meet in the home with your adult client and their children, coaching and guiding them through use of their coping skills to interact more positively with their children.
3. Couples work with an adult client and their partner.
Yes! Could be H0032 (you are reviewing ways to implement treatment at home within the bounds of what has been agreed upon in the ITP) or H2014 w/out client (you are teaching those skills to the caregiver; be sure to mention why client was not present). POS should be air/ambulance
Staff billed this 11-minute session as family skills. Why is this not compliant?
Objective: List preferred coping skills and demonstrate one per session
Interventions/response: Sally’s dad went to her room to get her for session. This writer heard dad prompt Sally to begin session. Sally yelled no. Dad prompted Sally to talk to this writer. This writer waited for Sally, who continued to yell No at her dad. Dad and this writer volleyed conversation about current functioning and then ended session when Sally would not join.
Objective was not met. Writer plans to continue working on coping skills.
1. Objectives in the ITP were not addressed. 2. Staff did not teach, model, prompt, coach, or positively reinforce w/ the caregiver.
Does a caregiver need to be present to bill family services with client and siblings or cousins?
Nope!
You receive a phone call from your client's dad, who is fuming because your client is failing classes. You listen and allow him to vent, empathize with him, and validate his concerns. He asks if you can address the issue of client's failing grades in your next session.
Client's current ITP is focused on emotion regulation and includes family skills and therapy hours. How do you document this time? Can you get CC for it?
If this is all that occurred in session, then depending on what program you are in, you would bill as SLMH caregiver consult or as a TW caregiver communications. But, this is a perfectly clinically appropriate time to provide additional support and teaching that addresses goals on the ITP (moving client closer to reaching those goals), and also getting you billable credit for it.
It depends on the content of the conversation and the way in which are were purposeful in making this a teachable moment with caregiver.It would also be beneficial to ask about caregiver's perception of client's emotion regulation and whether client has been observed using any of the strategies taught in session. If so, it would then be important to teach the benefits of praise when client is able to use those skills. If not, teach the caregiver what to look for to praise them, or to prompt/coach them to use the skills. This could be family skills or family therapy w/out client present.
True or false: You can address parenting skills in ARMHS work
Technically false but partly true. We cannot include parenting skills in ARMHS ITPs/progress notes. It is clinically appropriate, however, to address emotion regulation (for example) while an ARMHS client is at home with their children in their parenting role.
You call a caregiver of a new client you are opening - DA is completed and the case has been assigned to you. What are some ways to approach the initial, introductory call to be most clinically helpful to the family and to your work in starting with this client (and also billable)?
1. Review the file thoroughly beforehand
2. Consult with any staff who worked with that client, including the DA writer
3. Have a list of questions for the caregiver regarding functioning, preferences, previous experiences in mental health, solutions they've tried, etc.
4. After you introduce yourself, ask if they have a few minutes to talk.
5. Ask open ended questions
6. Ask for examples of behaviors and concerns
7. Ask about frequency, duration, and intensity of behaviors and concerns
8. Reflect your understanding of the issue as seen by the caregiver; ask for clarification or whether you fully understand
9. Ask what has been helpful for addressing these issues in the past. What has gotten in the way of using previously helpful strategies?
10. Explain appropriate clinical strategies for addressing these type of problems (you would have been able to do some of this work beforehand based on your research and supervision), such as working with the caregiver to ensure that child can make as much progress as possible.
11. Ask about their thoughts and potential barriers to meeting or keeping child in services. It is appropriate to expect a caregiver of a child under age 10 to commit to weekly meetings, bi-weekly, or monthly at an absolute minimum.
12. Clearly outline next steps for them (i.e., you will begin writing the plan, meet with them at the agreed upon time to review and expand on the plan, etc.)
13. Show empathy! Ask how they've been handling these challenges and taking care of themselves. Are there any ways you can help with this?
You meet with your client at home. Grandma is making dinner, so you suggest meeting at the kitchen table near Grandma. You and client play games to practice impulse control. Grandma does not play. You praise client for waiting their turn, prompt them to wait their turn a few times, and teach the importance of waiting their turn. You ask client to explain to Grandma why it's important to wait your turn, and they do so. Grandma responds throughout by looking but does not comment. When session ends, you praise client again for their progress and ask Grandma to play a game with them over the next week to practice taking turns. Grandma agrees.
How should you bill and what are important details to include in the note?
This session should be billed as a family session. Note should focus on how you modeled prompting and praising for Grandma, and how client and Grandma responded to those strategies. Also include teaching the importance of taking turns and teaching Grandma that playing games is a good way to practice impulse control. In the plan section, mention Grandma's "homework."
If you were in this situation, how would you ensure that you could still provide a clinically appropriate service within this interaction to provide family skills with the dad?
Objective: List preferred coping skills and demonstrate one per session
Interventions/response: Sally’s dad went to her room to get her for session. This writer heard dad prompt Sally to begin session. Sally yelled no. Dad prompted Sally to talk to this writer. This writer waited for Sally, who continued to yell No at her dad. Dad and this writer volleyed conversation about current functioning and then ended session when Sally would not join.
Objective was not met. Writer plans to continue working on coping skills.
1. Inquire about Sally's use of skills addressed in the ITP (that you've been working on with her) in the home **If this is all that's addressed and you don't prompt, praise, positively reinforce, etc., with caregiver, this can be treatment plan review
2. Ask Dad about any successes over the past week related to the skills on the ITP and praise Dad for recognizing them - ask if he provided any positive reinforcement to Sally and praise him for doing so. Dictate as such.
3. While volleying conversation about current functioning, ask specific questions about Dad's use of strategies (what has been working for you lately? what hasn't been working)?, problem solving issues, modeling and teaching strategies to use.
4. If Dad only has time for a brief conversation, be sure to do one of the strategies above, and depending on your relationship with the family, ask whether it would be okay to wait and see if Sally comes around. Can you give a note to Dad to give Sally to communicate? She might come around with time.
You're starting to notice a pattern where, nearly every time you meet with your new client, the caregiver spends the majority of session venting, complaining about their stress, and wanting to co-ruminate about the latest crisis. Knowing the importance of caregivers' mental health on your client, and also wanting to establish boundaries and to ensure that client's needs are met, what are some strategies you can use to support the caregiver?
1. Be open about your observation with the caregiver in a nonjudgmental, empathetic manner.
2. Explain your role
3. Inquire about their needs
4. Offer ideas like arriving earlier or staying later for 1:1 time w/out client, with the agreement that focus is ultimately on client and so you will redirect back on topic if need be; phone check-ins midweek (same agreement); opening caregiver for individual services; caregiver practicing emotion regulation and relaxation skills with client in sessions and as homework; giving caregiver strategies for self care and relaxation as homework; connecting to case management if appropriate.
We understand the importance of working with families to treat children's mental health. Why is it important to use family services codes to document time spent doing so?
Acceptable responses can include:
1. It is ethical to document who was present in services and to what extent, and to provide an honest account of what occurred.
2. When we have data on the number of family sessions provided or hours of family services provided for a given client, we can use this information to understand the client's progress or lack thereof. Having accurate data on a client's services and functioning can help us to make sound clinical decisions that are more objective rather than subjective.
3. Involving families in services for the treatment of many types of children's mental health conditions is, in and of itself, a practice based in evidence and can be considered "best practice". By documenting our efforts we are proving that we are providing clinically excellent service.
4. To show DHS, who oversees our certification for various programs (e.g., CTSS), that we are providing family centered services within the guidelines of these programs.