CLINICAL DOCUMENTATION GUIDE - Contra Costa County

1 CLINICAL DOCUMENTATION GUIDE 2017 Contra Costa County BEHAVIORAL HEALTH Contra Costa County DOCUMENTATION Manual v 2017 2 TABLE OF CONTENTS Chapter 1 Introduction/Compliance Why do we have this manual? 4 Compliance 5 Utilization Review 6 Chapter 2 General Principles of DOCUMENTATION General Principles of DOCUMENTATION 7 Signatures 9 Co-Signatures 9 Chapter 3 Establishment of Medical Necessity Flow of CLINICAL Information 10 Assessment 10 Medical Necessity 11 Components of Medical Necessity 13 Diagnostic Criteria 13 Impairment Criteria 13 Intervention Criteria 14 Chapter 4 Treatment Planning Partnership Plan for Wellness 15 Client Participation and Signatures 16 Timeliness of Partnership Plans 16

2 Revisions to the Plan 17 Components of the Partnership Plan 17 Partnership Plan Process Elements 17 Component Details and Examples 18 Partnership Plan Dates 18 Client Strengths 18 Life Goals 19 CLINICAL Treatment Goals 19 Strategies to Achieve Goals 21 Service Modalities 22 Chapter 5 Utilization Review Track Establishment of the UR Track 23 Timeframes for Submission of DOCUMENTATION for Service Authorization 23 Additional Treatment Team Providers 24 Annual Renewal of Services 24 Chapter 6 Progress Notes General Guidelines for Documenting Medical Necessity for Progress Notes 26 Timeliness of DOCUMENTATION of Services 28 Frequency of DOCUMENTATION 28 Progress Note Service Definition 29 Assessment (331) 29 Evaluation (313) 30 Plan Development (315) 30 Collateral (311) 31 Rehabilitation (317) 32 Individual Therapy (341)

3 33 Group Therapy/Group Rehab/Group Collateral 34 Medication Support Services 35 Case Management Brokerage 36 Crisis Intervention 37 Non Billable Services 38 Contra Costa County DOCUMENTATION Manual v 2017 3 Lockouts and Limitations 39 Service Type Comparison 40 Chapter 7 Scope of Practice/Competence/Work CCMHP Professional Classifications and Licenses 43 Scope of Practice Grid 46 Chapter 8 Medication Consents Medication Consent 47 Chapter 9 DOCUMENTATION Requirements for Specific Program Types Medication Clinic DOCUMENTATION Guidelines 48 Chapter 10 Special Populations Katie A.

4 Subclass 49 Katie A Service Procedures 49 Katie A: Certain Restrictions Apply to the ICC & IHBS Procedure 50 Therapeutic Behavioral Services (TBS) Class 50 TBS Services 50 TBS Service Procedures 51 Chapter 11 Examples Examples of Strengths 52 Examples of Intervention Words 52 Examples of Intervention Phrases for Specific Psychiatric Symptoms, Conditions 52 Examples of Progress Notes 56 Examples of Partnership Plan Goals 61 Appendices Appendix A. Medi-Cal Included Diagnosis Groups 63 Appendix B. DSM 5 Crosswalk 64 Appendix C.

5 Title 9 Service Definitions 70 Appendix D. Scope of Practice Grid 72 Appendix E. Abbreviations 73 Appendix F. Policies & Forms 80 Contra Costa County DOCUMENTATION Manual v 2017 4 WHY DO WE HAVE THIS MANUAL? This manual was developed as a resource for providers within Contra Costa Mental Health Plan (CCMHP) which include County owned and operated programs and Community Based Organizations (CBOs). It outlines standards and practices required within the Children, Youth and Family, Katie A, Forensics, Transitional Services, and Adult & Older Adult systems of care.

6 It serves to ensure that providers within CCMHP meet regulatory and compliance standards of competency, accuracy, and integrity in the provision and DOCUMENTATION of their services. This manual will be posted at the following website: As with any manual, updates will need to be made as policies and regulations change. When updates are distributed, please be sure to replace old sections with updated sections. Please note that this is primarily a CLINICAL DOCUMENTATION GUIDE , , the main focus throughout this manual is the CLINICAL DOCUMENTATION in the medical record.

7 Sources of information This CLINICAL DOCUMENTATION Manual is to be used as a reference GUIDE and is not a definitive single source of information regarding chart DOCUMENTATION requirements. This manual includes information based on the following sources: Code of Federal Regulations (CFR) 45 and 42, the California Code of Regulations (Title 9), the California Department of Health Care Services (DHCS) Letters and Information Notices, American health Information Management Association (AHIMA), the Contra Costa County policies and procedures, directives and the Quality Improvement & Utilization Review Department s interpretation and determination of DOCUMENTATION standards.

8 Chapter 1. INTRODUCTION/COMPLIANCE Contra Costa County DOCUMENTATION Manual v 2017 5 COMPLIANCE Contra Costa County Behavioral Health Services is a County behavioral health organization (also referred to as Contra Costa Mental Health Plan; CCMHP) that provides services to the community and then seeks reimbursement from state and federal funding sources. There are many rules associated with billing the state and federal government, thus the need for this DOCUMENTATION GUIDE . In general, good ethical standards meet nearly all of the requirements.

9 At times, there is a need to provide some guidance and clarity so staff can efficiently and effectively document for the services they provide. CCMHP has adopted a Utilization Review Department based on guidance and standards established by the Office of Inspector General, Department Health and Human Services. The Office of Inspector General (OIG) is primarily responsible for Medicare and Medicaid fraud investigations and provides support to the US Attorney s Office for cases which lead to prosecution. The State of California also has a Medicaid/Medicare Fraud Control Unit.

10 Many California County behavioral health departments have already been investigated by State and Federal agencies, and in all of those counties either severe compliance plans or fraud charges have been implemented. The intent of the compliance plan is to prevent fraud and abuse at all levels. The compliance plan particularly supports the integrity of all health data submissions, as evidenced by accuracy, reliability, validity, and timeliness. As part of this plan we must work to ensure that all services submitted for reimbursement are based on accurate, complete, and timely DOCUMENTATION .