Medical Necessity Madness
When a service is "reasonable and necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain." All Medi-Cal services provided need to meet this standard.
What is Medical Necessity?
Administrative tasks, transportation, services that occur after a member's death, and any activity that is not a specialty mental health service/intervention.
What is Non-Billable?
This group focuses on helping members deal with cravings, harm reduction, and other important matters to help them in their recovery, but it still has to be documented as secondary to their mental health.
What is a SUD group?
The deadline for when progress notes are due.
What is 24 hours?
Administrative tasks, like reviewing records, completing clinical documentation, entering DCR data, emailing/texting/leaving messages, and confirming/rescheduling appointments.
What is non-billable?
This requirement is the fundamental criteria of medical necessity. Hint: it's acronym is SMHS.
What is Specialty Mental Health Services?
Documents that must be in place in order to bill for peer services and targeted case management.
What is a Peer Plan and Care Plan note?
A critical team member that assists the member in a lot of different areas, but cannot bill or use words like "assess," "therapy," or "educating them about their medications."
Who is Case Manager?
The deadline for when supervisors need to sign off on progress notes.
What is 72 hours?
When our program has to pay money back to the County because of improper billing and documentation.
What is recoupment?
Interventions and service modalities like Motivational Interviewing, CBT, and DBT.
What are Evidence-Based Practices?
A service geared toward improving the member's functioning in their various life domains by utilizing skill-building via modeling, practicing, coaching, and psychoeducation and DOES NOT involve case management activities like care coordination and monitoring progress.
What is Rehab?
All of my progress notes require a co-signature until I have a little more experience.
What is a PP-2?
The living document that contains diagnoses and SDOH that is completed within the first 30 days and updated as clinically indicated.
What is the Problem List?
A service that assesses a member's needs and connects them to different services and resources to meet their needs and includes referrals and monitoring progress.
What is targeted case management (TCM)?
A decline in a member's ability to achieve tasks in a life domain, such as social, relational, or occupational, due to their behavioral health condition.
What is functional impairment?
When my progress note says that I met with the member at their B&C to discuss coping skills, then gave them a ride to the grocery store, and then went back to the B&C and talked to the staff there to discuss the member's next psychiatry appointment.
What is a bundled service?
Someone who helps to run a group and is also responsible for documenting their unique interventions during the group.
Who is a Co-Facilitator?
The document that MUST be completed BEFORE billing targeted case management and no longer counts for peer support services.
What is the Care Plan note?
The accrediting body that will be coming this winter and will be evaluating the program's practices, including documentation.
What is CARF?
Z codes found in the Problem List that are the conditions and environments in which people are born, live, work, play, etc. that affect someone's health, functioning, and quality of life.
What are Social Determinants/Drivers of Health?
All of my service time is an hour because it's any easy system for me to implement.
What is fraud?
Performing tasks, duties, or services that a professional is not educated, certified, licensed, or competent to perform. It involves exceeding the established legal or professional boundaries of one’s role, which can lead to liability, patient harm, and loss of licensure.
What is outside of scope of practice?
When I don't document my time billed accurately, like rounding up or down, using arbitrary times, and/or using the same times over and over again.
What is fraud, waste, and/or abuse?
The idea that it's ok to do whatever you want with documentation.
What is a _____ (problem, lie, delusion, etc.)?