Documentation
Billing for a session that didn’t happen is considered this.
What is Medicaid Fraud
Myth or Fact: Every therapy session and clinical services note must have an IPOC goal and objective from the treatment plan addressed.
What is a Fact?
Each billable service must be clinically tied to a goal and objective on the Individualized Plan of Care (IPOC). Medicaid requires that services demonstrate progress toward documented treatment goals to ensure medical necessity and to justify reimbursement.
A parent requests copies of all your clinical notes on their child during a school meeting. What is the correct procedure?
Explain the process for formal record requests and provide notes per school/district policy and HIPAA/FERPA guidelines.”
Fill in the blanks for the Medicaid clinical service note requirements:
F: __________________________
I: Intervention: What interventions are being used today in session?
R: _____________________
P: Progress: You are measuring progress between the most recent session and the current note.
P: Plans for future: Specific intervention plans for the next session.
What are: Focus (or Focus of the session) and Response (client’s response to the intervention)?
The maximum duration of an IPOC is 365 days, but your client’s IPOC is now at 378 days. What must be done to regain Medicaid compliance?
What is: Do a Follow Up Assessment, update and re-sign a new IPOC with current assessment and goals before continuing to bill Medicaid?
IPOC Treatment plan goals must be SMART. What does SMART stand for?
What is Specific, Measurable, Achievable, Relevant, Time-bound?
Myth or Fact? All Medicaid Documentation must be completed within 24 hours.
What is a Myth?
While timely documentation is required, the exact time frame can vary by agency policy or state Medicaid guidelines. Many providers aim to complete notes within 24-72 hours to ensure accuracy and compliance, but 24 hours is not always a strict Medicaid mandate.
A new school-based client begins discussing another student who is also your client. You recognize this creates a confidentiality conflict. What do you do next?
What is gently redirect the conversation and explain that you cannot confirm or discuss anything about other clients due to confidentiality
Medicaid requires that all progress notes include the date, time, type of service, and _______________ of the clinician providing the service.
What is signature?
If a client has not received services in 45 consecutive calendar days, medical necessity must be reestablished by completing a __________________________ ?
What is a re-assessment or updated diagnostic assessment?
A client shows new or worsening symptoms, and you believe their services need to be added or changed. These are the clinical and documentation steps you must take before providing and billing for new services.
What are: reassess the client (FUA), document the changes (Clinical Service Note), update the treatment plan (IPOC addendum) and begin new services only after all steps are complete?
Myth or Fact: Clinicians must document any safety risks disclosed during a session.
What is a Fact?
Documenting safety risks (like suicidal ideation, self-harm, abuse, or violence) is critical for clinical care, legal protection, and compliance with Medicaid standards. It ensures proper follow-up, risk management, and continuity of care.
While having lunch, a teacher casually asks to see a student’s clinical notes and diagnostic assessment. You should do this.
What is politely decline and explain that this information is confidential and protected under HIPAA and FERPA?
______________ is a required document signed by the guardian that gives permission to provide and bill Medicaid for mental health service
Consent to Treat and Bill Medicaid
A clinician notices an overdue progress summary during a mini audit. What must she do to avoid potential Medicaid paybacks?
What is: complete and submit the overdue progress summary as soon as possible and document any reasons for the delay?
_______________ dates are on the IPOC as a timeline for completion that is individualized to each goal and objective?
What is Target Dates
Myth or Fact? Copies of the IPOC for the initial assessment must be signed by all parties and distributed within 30 calendar days; copies for follow-up assessments must be signed and distributed within 10 calendar days.
What is Fact?
This timeline aligns with many Medicaid and state mental health program requirements to ensure timely communication and agreement on the treatment plan between clinician, client, and guardians.
If a therapy session ends early due to a fire drill and only lasts 12 minutes, this should be done in documentation.
What is document the actual time and reason for early termination; do not bill unless minimum time threshold is met
If you make an error on a Medicaid note or document you have to print off and make the following corrections:
1. Clearly draw a Line through the error
2. Write _____________ beside the error.
3. Make the correction
4. initial and date the correction
What is Error?
True or False: Functional Assessments are optional when completing Initial and Follow Up Assessments.
What is False?
Functional Assessments are a required component of Initial and Follow-Up Assessments to evaluate the client’s strengths, needs, and impairments, which guide treatment planning.
The progress summary shall be completed at least every 90 calendar days from the signature date on the initial _______________________, and at least every 90 days thereafter.
What is IPOC?
Myth or Fact? The progress summary should always include the appropriateness and frequency of services provided, AND any failure to provide the recommended services at their frequency should always be explained.
What is Fact?
Medicaid requires progress summaries to reflect whether services are meeting the client’s needs and to explain any missed or reduced sessions, ensuring transparency and accountability for treatment.
A frustrated principal storms into your office and demands you begin seeing a student twice a week for mental health services. What is your ethical and clinical response
What is calmly explain that mental health service frequency is determined by clinical assessment, medical necessity, and the treatment plan — not administrative demand?
Fill in the Blank: What has to be included in the Discharge Plan Section of the Individualized Plan of Care (IPOC):
1. Action Plan for discharge
2. Client's and Families expected _________
2. The anticipated date of the discharge
3. Anticipated After Care Services Needed
What is expected outcomes, goals or gains?
During a Medicaid audit, missing or incomplete documentation for billed sessions can result in what consequences?
What are denied claims, paybacks, and potential sanctions?