Billable or Nah?
Video session with 15 year old client, for 30 minutes.
Yes.
A 30 minute therapy session held in person, with a 15 year old client.
R30
A 45 minute session held in-person.
Individual template
Find the Comprehensive Intake form - Part 1 and 2 for any client admitted after May 2021.
Electronic Health Record > Assessments/Forms. If the client was admitted prior to May 2021, you will find the Core History and Core Evaluation forms in IMA.
I can provide telemental health services through zoom.
False. All video sessions must be conducted via Doxy using your NYPCC account, which complies with HIPPA regulations. Microsoft TEAMS and Zoom can/will be used for meetings/trainings.
V30 session is disconnected at the 15 minute mark and you are unable to reconnect with the client.
Nah. The expected duration is 30 min (minimum 16 min) but you can call the client back to continue the session or document as a CM.
A collateral session with the mother of your 13 year old client that goes on for 45 minutes, held via telephone.
TCO. The expected duration for a COL session is 30 minutes and is billable within 26+ min at the same rate. However, if the session runs over you should use the actual start/end times in your progress note.
Session held with a foster parent, on the phone for 30 minutes, client not present.
Collateral template. The client does not need to be present during a COL session, but can be present for some or all of the session as clinically indicated.
Locating a phone number to call a client
1. Full EHR > Demographics
2. Lookup > Client Lookup
If a client does not provide their address/location at the start of the telemental health session, I should still proceed with the session.
False. The client must provide their exact location (address/apt # and/or cross streets) so that EMS can locate them in case of emergency.
V30 session with a client lasts 25 minutes, client reports that they have to end session to catch the bus to work.
30 minute video session with 6 year old client, collateral is present for 10 minutes of the session.
V30. This is an individual session since the child was present for the full duration, even if the COL is present for part of the session. The progress note should include the COL's name, relationship and participation.
In-person session with a 3 year old client, for 30 minutes.
Individual.
Find the suicide risk assessment.
CSSRS - Located in EHR > Assessments/Forms
I must use the IMA-write template for all of my progress notes (except CM notes).
True. There are templates for all billable progress note types and for some non-billable notes (e.g. No-Show) that are used for multiple activity codes. However, for a CM note you do not need to use the template.
A client texts you that they are stressed out and in need of therapeutic support.
Nah. This text exchange is not billable, but you can offer to schedule a session for later in the day/week.
48 minute video session with 29 year old client.
V45. These sessions have an expected duration of 45 min, but are billable from 38+ min. Remember to use V-codes for video sessions in order to include the video session prompt at the beginning of the progress note.
A 35 year old client reports S/I with plan and intent during the session. EMS/911 are contacted and client is transported to the nearest hospital.
Crisis template. Always consult with supervisor when safety concerns arise, and ask a supervisor/trainer to review this note before signing.
Find the collaterals listed for your client and demonstrate how to edit/add.
EHR> Full Electronic Health Record > Collaterals (tab)
OR
Client Registration/Services/Schedule > Client collaterals
I can provide my client with any records that they request.
False. A HIPPA form is required for outside entities, and therapists should discuss appropriateness/need with client, then submit requests to the Medical Records Dept. Therapists may provide a copy of the Safety Plan and IMA-calendar Appointment Slips only.
Client calls 2 hours before therapy session to cancel session.
Nah. This should be coded as a NS. The next appointment should be confirmed and scheduled with the client.
In person, 1 hour long session with client and his mother. Client is present for 31 minutes of the session, Mother is present the entire time.
FAM. A family session has an expected duration of 1 hour, but is billable if clinically appropriate at 50+ min.
Client calls one day ahead of time to cancel a therapy appointment.
No Show. The NS template should be used to document the content of the note, and the CAN activity code can be used to indicate that the session was cancelled at least 24 hours in advance.
Find the treatment plan for any client already admitted to the clinic (i.e. transfer client).
IMA homepage > Electronic Health Record > Treatment Plan > Highlight Client > View/Edit/Sign/Print
Clients are told about confidentiality during the intake process. I do not need to tell them as well.
False. Therapists should review confidentiality and limitations for safety concerns during the initial session, even if the client was informed by the intake worker and/or a previous therapist.