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Documentation Requirements for Psychotherapy

Melissa S. HooksDirector of Program Integrity

Overview of PresentationOverview of Presentation

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Documentation Requirements for Payment• Consent Form• Treatment Plan• Progress Note• Encounter Form

Overview of Documentation Requirements

Program Integrity Documentation RequirementsProgram Integrity Documentation Requirements

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Review the documentation requirements to receive payment from VBH-PA

Provide specific documentation requirements Identify potential audit findings

Consent Forms

Consent FormsConsent Forms

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Main Purpose of Consent Forms1. Obtain consent to diagnosis or treat2. Obtain consent to release health information for

payment and continuity of care

PA Regulations for Consent FormsPA Regulations for Consent Forms

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Pennsylvania Code • Chapter 1101 General Provisions

http://www.pacode.com/secure/data/055/chapter1101/chap1101toc.html § 1101.75. Provider prohibited acts.

a) An enrolled provider may not, either directly or indirectly, do any of the following acts:

10) Except in emergency situations, dispense, render or provide a service or item without a practitioner’s written order and the consent of the recipient or submit a claim for a service or item which was dispensed or provided without the consent of the recipient.

VBH-PA Requirements for Consent FormsVBH-PA Requirements for Consent Forms

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VBH-PA Provider Manual • Treatment Records

http://www.vbh-pa.com/provider/info/prvmanual/4_PartPrvResp/tx_record_standards.htm

Participating providers are expected to maintain clinical record keeping systems that meet the following basic requirements:

• 8) Each record includes the patient’s address, employer or school, home and work telephone numbers, emergency contacts, marital/legal status, appropriate consent forms and guardianship information, if relevant;

• 26) Informed consent for medication and the patient’s understanding of the treatment plan are documented;

VBH-PA Fraud and Abuse Webpage• Coming Soon!

Minimum Documentation for Consent FormsMinimum Documentation for Consent Forms

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Informed consent prior to treatment, with the following elements:

• The diagnosis• The nature and purpose of a proposed treatment or service• The benefits and risks of the proposed treatment or service• Alternatives including benefits and risks• The risks and benefits of not receiving treatments or services

AMA 1998

*Consent should be referenced in the treatment plan.

Minimum Documentation for Consent FormsMinimum Documentation for Consent Forms

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Consent Form should include the following:• Name and signature of the patient, or if appropriate, legal

representative • Name of the provider • Type of services or treatment• Name of all providers• Benefits and any potential risks • Alternative procedures and treatments and their risks • Date and time consent is obtained • Statement that procedure was explained to patient or guardian • Signature of person witnessing the consent • Name and signature of person who explained the procedure to the

patient or guardian Federal Code (Title 42 C.F.R. § 482.51 (b) (2)) Interpretive Guideline A-0392

Consent to Treatment FindingsConsent to Treatment Findings

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VBH-PA Program Integrity Potential Findings• No consent to treatment in member record• Consent to treatment was not signed• Consent to treatment was signed after the treatment plan• Consent to treatment was signed after services were provided

Treatment Plans

Treatment (Service) PlansTreatment (Service) Plans

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Main Purpose of Treatment (Service) Plans1. Definition of Treatment

Goals and Objectives Utilization

2. Description of Informed Consent As recorded on the Consent Form

3. Mechanism to Track Individual Plans, Treatments, and Outcomes throughout Treatment

PA Regulations for Treatment PlansPA Regulations for Treatment Plans

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Pennsylvania Code • 1101 General Provisions

http://www.pacode.com/secure/data/055/chapter1101/chap1101toc.html 1101.51. Ongoing responsibilities of providers.

(1) General standards for medical records. A provider, with the exception of pharmacies, laboratories, ambulance services and suppliers of medical goods and equipment shall keep patient records that meet all of the following standards:

(v) Treatments as well as the treatment plan shall be entered in the record. Drugs prescribed as part of the treatment, including the quantities and dosages shall be entered in the record. If a prescription is telephoned to a pharmacist, the prescriber’s record shall have a notation to this effect.


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Pennsylvania Code • 1223.42. Ongoing responsibilities of providers.

http://www.pacode.com/secure/data/055/chapter1223/s1223.42.html In addition to the requirements listed in Chapter 1101, the following items

shall be included in medical records of Medical Assistance patients receiving drug/alcohol outpatient clinic services:

• As part of the treatment plan, the treatment plan goals; services to be provided to the patient in the clinic or through referral; and persons to directly provide each service shall be included.

VBH-PA Requirements for Treatment PlansVBH-PA Requirements for Treatment Plans

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3. Accurately document at least the following on each case for which services are being provided:

a. Member information (demographic);b. Clinical information;c. Clinical assessments;d. Treatment plans;e. Services provided;f. Contacts with member’s family, guardians or significant others;g. Treatment outcomes; andh. PCPC/ASAM for substance abusers;


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5. All members’ treatment records must contain a bio-psychosocial assessment; treatment plan, follow-up assessments, focus of treatment and disposition/discharge plan. Medical and psychological treatment documentation and progress notes must be current and treatment plans shall be updated as necessary for the level of care.

6. It is necessary that the provider initiating treatment document an initial treatment plan that describes the active target interventions with specific, measurable goals, and stated in behavioral terms, at the level of care proposed;


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24. Treatment plans are consistent with diagnoses and have objective, measurable goals and estimated time lines for achieving goals or resolving problems;

25. The focus of treatment interventions is consistent with the treatment plan goals and objectives;

26. Informed consent for medication and the patient’s understanding of the treatment plan are documented;

27. Progress notes describe the patient’s strengths and limitations in achieving treatment plan goals and objectives;


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VBH-PA Fraud and Abuse Webpage• Minimum Documentation Standards for Payment:

http://www.vbh-pa.com/fraud/pdfs/Minimum-Provider-Documentation-Standards-for-Payment.pdf

A. Treatment Plan: Minimum Requirements for Payment for all Provider Types:

1. Must be completed according to service requirements2. Treatment plan date3. Diagnoses and/or symptoms addressed4. Clinician’s signature, credentials, and signature date5. Member or guardian’s signature and signature date6. Evidence member or guardian participated with treatment plan development7. Goals and objectives based on evaluation and mental health strengths and needs


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8. Treatment objectives and prescribe as an integrated program of therapies, activities, experiences, and appropriate education designed to meet these objectives9. Treatment goals are measurable10. Treatment goals have established timeframes11. Treatment plan address notes less restrictive alternatives that were considered12. Treatment plan is easy to read and understand13. Treatment plan documents necessity for services14. Treatment plan documents the utilization of services


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Clinical Tips for Treatment Plans• Include diagnosis with symptoms and behaviors as identified

on the evaluation or assessment• Identify strengths and needs• Define utilization of services, such as frequency• Continuously monitor and update the treatment plan

Treatment Plans FindingsTreatment Plans Findings

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VBH-PA Fraud and Abuse Webpage• Common Audit Exceptions and Findings

http://www.vbh-pa.com/fraud/pdfs/Program-Integrity-Exceptions-and-Findings.pdf

Clinical Documentation Exceptions and Findings:• No valid treatment plan for date of service• Incomplete treatment plan for date of service

Missing member/parent signatures Does not include frequency of services, such length of service and session

per week or month Does not include diagnosis and/or symptoms and behaviors Does not describe consent to treatment and/or member/parent

involvement Treatment goals and objectives are not measurable Treatment goals and objectives do have timeframes Treatment plan does not reference information from evaluation

Progress Notes

Progress NotesProgress Notes

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Main Purpose of Progress Notes1. Document progress at each visit, change in diagnosis,

change in treatment and response to treatment2. Document medical necessity and justification for

payment from Medical Assistance

PA Regulations for Progress NotesPA Regulations for Progress Notes

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http://www.pacode.com/secure/data/055/chapter1101/chap1101toc.html §1101.51. Ongoing responsibilities of providers.

1. General standards for medical records. A provider, with the exception of pharmacies, laboratories, ambulance services and suppliers of medical goods and equipment shall keep patient records that meet all of the following standards:

i. The record shall be legible throughout. ii. The record shall identify the patient on each page. iii. Entries shall be signed and dated by the responsible licensed

provider. Care rendered by ancillary personnel shall be countersigned by the responsible licensed provider. Alterations of the record shall be signed and dated.


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http://www.pacode.com/secure/data/055/chapter1101/chap1101toc.html §1101.51. Ongoing responsibilities of providers.

1. General standards for medical records. A provider, with the exception of pharmacies, laboratories, ambulance services and suppliers of medical goods and equipment shall keep patient records that meet all of the following standards:

i. The record shall be legible throughout. ii. The record shall identify the patient on each page. iii. Entries shall be signed and dated by the responsible licensed

provider. Care rendered by ancillary personnel shall be countersigned by the responsible licensed provider. Alterations of the record shall be signed and dated.


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iv. The record shall contain a preliminary working diagnosis as well as a final diagnosis and the elements of a history and physical examination upon which the diagnosis is based.

v. Treatments as well as the treatment plan shall be entered in the record. Drugs prescribed as part of the treatment, including the quantities and dosages shall be entered in the record. If a prescription is telephoned to a pharmacist, the prescriber’s record shall have a notation to this effect.

vi. The record shall indicate the progress at each visit, change in diagnosis, change in treatment and response to treatment.

vii. The record shall contain summaries of hospitalizations and reports of operative procedures and excised tissues.


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viii. The record shall contain the results, including interpretations of diagnostic tests and reports of consultations.

ix. The disposition of the case shall be entered in the record. x. The record shall contain documentation of the medical

necessity of a rendered, ordered or prescribed service.


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Pennsylvania Code • 1223.42. Ongoing responsibilities of providers.

http://www.pacode.com/secure/data/055/chapter1223/s1223.42.html In addition to the requirements listed in Chapter 1101, the following items

shall be included in medical records of Medical Assistance patients receiving drug/alcohol outpatient clinic services:

• As part of the progress notes, the frequency and duration of each service provided shall be included.

VBH-PA Requirements for Progress NotesVBH-PA Requirements for Progress Notes

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Participating providers are expected to maintain clinical record keeping systems that meet the following basic requirements:

5) All members’ treatment records must contain a bio-psychosocial assessment; treatment plan, follow-up assessments, focus of treatment and disposition/discharge plan. Medical and psychological treatment documentation and progress notes must be current and treatment plans shall be updated as necessary for the level of care.

Minimum Documentation for Progress NotesMinimum Documentation for Progress Notes

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VBH-PA Requirements for All Providershttp://www.vbh-pa.com/fraud/pdfs/Minimum-Provider-Documentation-Standards-for-Payment.pdfI. In addition to VBH-PA requirements in this section and in the VBH-PA Provider

Manual, all providers are responsible to follow all requirements under Pennsylvania Medical Assistance regulations, publications, and bulletins.

II. All providers must have member charts that include all requirements as defined in the Pennsylvania Code Provider Responsibilities regulations and VBH-PA Provider Manual to support the claims billed.

III. All documentation must meet the requirements of the service codes that are submitted on the claims form.

IV. All requirements for documentation must be completed prior to the claim form submission date.

V. All requirements must be legible.


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VBH-PA Requirements for All ProvidersVI. All encounters must have a progress note to support the service billed.VII. All direct encounters must have an encounter form to verify services.VIII. All amendments or changes to the documentation must be signed and dated

by the clinician amending or changing the documentation.IX. Training related to documentation standards is located at: http://www.vbh-

pa.com/provider/prv_trn.htm


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VBH-PA Requirements for All ProvidersX. All providers must have the following minimum documentation for treatment

plans, encounter forms, and progress notes to receive payment for claims billed:C. Progress Note: Minimum Requirements for Payment for all Provider Types:

1. Must be completed for each billable encounter2. Name or Medical Assistance identification number3. Date of service4. Start and stop times of service5. Units match the claims billing6. Place of service (specific location for community services)


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VBH-PA Requirements for All ProvidersX. All providers must have the following minimum documentation for treatment

plans, encounter forms, and progress notes to receive payment for claims billed:C. Progress Note: Minimum Requirements for Payment for all Provider Types:

7. Reason for the session or encounter8. Treatment goals addressed9. Current symptoms and behaviors10. Interventions and response to treatment11. Next steps and progress in treatment12. Narrative with the clinical justification to support utilization and time

billed13. Supporting documentation, when applicable14. Clinician’s signature, credentials, and signature date

Progress Notes FindingsProgress Notes Findings

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VBH-PA Program Integrity Potential Findings• Progress notes do no support medical necessity or the time

billed: Pennsylvania Code and regulations specifically state that

providers must Fully disclose and describe the services that are billed under Medical Assistance:

• The record shall indicate the progress at each visit, change in diagnosis, change in treatment and response to treatment

• The progress note must specific services rendered• The progress note must support medical necessity and justify the time

billed The treatment plan should define the utilization and support the

medical necessity for the frequency and length of service Then the progress note should fully disclose the service

provided


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VBH-PA Program Integrity Potential Findings• Non-billable service documented in progress notes

Case management, central intake or records, training, administration, social rehabilitation, program evaluation or research

Travel and transportation Cancelled appointments Clinic service provided over the telephone

• Please note that documenting non-billable services is still necessary but can not be submitted for payment


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VBH-PA Program Integrity Potential Findings• VBH-PA Audit Exceptions

http://www.vbh-pa.com/fraud/pdfs/Program-Integrity-Exceptions-and-Findings.pdf No progress note No services were rendered (no shows) No narrative Progress note is illegible Inaccurate units billed Progress note does not provide specific location Progress note does not have start and stop times


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Rounding units • Exception case management and resource coordination

Services were unbundled and billed individually• This applies when services are paid by events or per diems • Examples: crisis diversion and methadone maintenance


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Correction to note is not initialed and/or dated• In 2015, this could result in identified overpayment

Progress note details (service code, units, time) do not match encounter form or claim

Incorrect service code or modifier billed Progress note is not signed and/or dated by clinician


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VBH-PA Program Integrity Potential Findings• VBH-PA Clinical Audit Exceptions

http://www.vbh-pa.com/fraud/pdfs/Program-Integrity-Exceptions-and-Findings.pdf Progress note does not state reason for the encounter Progress note does not state treatment plan goals and objectives Progress note does not reference symptoms or behaviors Progress note does not have next steps in treatment Progress note does not state intervention Progress note or narrative is a duplication or almost a duplication

of previous note or narrative

Progress Notes TipsProgress Notes Tips

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Progress Note Clinical Tips• Leave enough room for a narrative that will fully describe the

services provided• In the narrative, explain the frequency, length, location,

intervention in relation to treatment plan and medical necessity to justify the payment from Medical Assistance

• Treatment goals and objectives can be listed but the narrative should describe the goals and objectives in terms of progress and the interventions utilized

• Fully describing the next steps in treatment will justify your necessity for continued services

Noncovered ServicesNoncovered Services

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§ 1223.14. Noncovered services.• Nonmedical counseling consisting of supportive activities to improve an

individual’s problem-solving and coping skills and intrapersonal or interpersonal development and functioning; and group recreation or group social activities, as group psychotherapy.

• Clinic visits, psychotherapy, diagnostic psychological evaluations, psychiatric evaluations and comprehensive medical evaluations conducted over the telephone, that is, any clinic service conducted over the telephone.

• Cancelled appointments. • Covered services that have not been rendered. • Inpatient hospital methadone maintenance.


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§ 1223.14. Noncovered services.• Vocational rehabilitation; day care; drug/alcohol or mental health partial

hospitalization; reentry programs, occupational or recreational therapy; Driving While Intoxicated (DWI) or Driving Under the Influence Programs or Schools; referral, information or education services; experimental services; training; administration; follow-up or aftercare; program evaluation; case management; central intake or records; shelter services; research; drop-in, hot-line or social services; inpatient nonhospital or occupational program services, or any other service or program not specifically identified as a covered service in Chapter 1150 (relating to Medical Assistance Program payment policies) and the Medical Assistance (MA) Program fee schedule.

• An MA covered service, including drug/alcohol clinic services, provided to inmates of State or county correctional institutions or committed residents of public institutions.


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§ 1223.14. Noncovered services.• Drug/alcohol outpatient clinic services provided to residents of treatment

institutions, that is, persons who are also being provided with room and board and services on a 24-hour basis by the same facility or distinct part of the facility or program. Drug/alcohol outpatient clinic services provided to residents of inpatient nonhospital and shelter facilities.

• Drug/alcohol outpatient clinic services provided to patients receiving psychiatric partial hospitalization services under the MA Program or drug/alcohol partial hospitalization services under the Department of Health.

• Covered drug/alcohol clinic services, with the exception of family psychotherapy, provided to persons without a drug/alcohol abuse or dependence diagnosis who are family members, other relatives, friends, acquaintances or live-in companions of the eligible recipient with a drug/alcohol abuse or dependence problem solely because of a relationship to the recipient. Payment will be made only for covered services directly provided to eligible MA recipients who have been diagnosed by a licensed physician as having a drug/alcohol abuse or dependence problem.


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§ 1223.14. Noncovered services.• Services delivered at locations other than approved drug/alcohol outpatient

clinics with the exception of home visits under the conditions specified in §1223.52(d) (relating to payment conditions for various services).

• Methadone maintenance clinic visits on days when the patient has take-home privileges, that is, self-administers methadone at home.

• Home visits not provided in accordance with the conditions specified in §1223.52(d).

• Methadone maintenance clinic services provided before the date of the physician’s comprehensive medical examination, diagnosis and treatment plan.

• Services provided without a level of care assessment for each patient prior to admission to the clinic.

• Services provided within or beyond the 15th calendar day following intake, without the clinic’s supervisory physician’s review and approval of the patient’s level of care assessment, psychosocial evaluation, treatment plan and determination of the patient’s diagnosis as specified in §1223.52(a)(6)(i).

Encounter Forms

Encounter FormsEncounter Forms

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Encounter Form1. Verify services were provided

Encounter form must be signed after the session

2. Meet the Federal regulations for Medicaid programs 42 CFR – Public Health www.gpo.gov

• 455.20 Recipient verification procedurea) The agency must have a method for verifying with

recipients whether services billed by providers were received

PA Regulations for Encounter FormsPA Regulations for Encounter Forms

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Pennsylvania Bulletins• PA Medical Assistance Bulletin #99-89-05• PA Medicaid Bulletin# 99-03-021, Health Insurance

Portability and Accountability Act (HIPAA) Transaction and Code Sets Updates, December 2003

VBH-PA Requirements for Encounter FormsVBH-PA Requirements for Encounter Forms

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http://www.vbh-pa.com/fraud/pdfs/Minimum-Provider-Documentation-Standards-for-Payment.pdf B. Encounter Form: Minimum Requirements for Payment for all Provider

Types:1. Must be completed for each billable encounter (except for services

that are excluded from encounter form requirements)2. Member name including member identification number (as required

in the PA Medicaid Bulletin)3. Type of service4. Date with start and stop times5. Total units billed6. Signature of Member for each encounter7. Clinician’s signature, credentials, and signature date

Encounter Form FindingsEncounter Form Findings

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VBH-PA Fraud and Abuse Webpage• Common Audit Exceptions and Findings

http://www.vbh-pa.com/fraud/pdfs/Program-Integrity-Exceptions-and-Findings.pdf

No encounter form Encounter form is not signed by member, parent, guardian, or

agent Encounter form does not include start and stop times Encounter form does not include type of service Encounter form not signed by clinician Correction to encounter form is not initialed and/or dated Encounter form details (service code, units, time) do not match

progress note or claim

Encounter Form Tips and RemindersEncounter Form Tips and Reminders

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Encounter Form Tips and Reminders• Encounter forms must be signed after the session to meet the

requirements• Encounter forms must be signed for all sessions to bill Medical

Assistance• Members should NEVER be asked to sign blank encounter

forms or sign prior to services being provided DPW considers this to be FRAUD

• VBH-PA sends member verification surveys and plans to send explanation of benefits (EOB)

• VBH-PA Training specific to member verification and encounter forms: http://www.vbh-pa.com/fraud/pdfs/Part-III_Search_for_Compliance.pdf

Questions???Melissa S. Hooks, DHCE(c), MS, AHFI, CFE

Director of Program IntegrityValue Behavioral Health of Pennsylvania

[email protected](724)744-6513

http://www.vbh-pa.com/fraud_abuse.htm

Search for Compliance - Arkansas PASSE Program · 2017-04-12 · Search for Compliance Methadone...

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Transcript of Search for Compliance - Arkansas PASSE Program · 2017-04-12 · Search for Compliance Methadone...