Medicaid Documentation Review - Colorado Health Partnerships

Medicaid Documentation
October 23, 2012
•Thank you for providing skilled professional treatment services to
Medicaid beneficiaries.
•Today we want to provide an update about required charting standards
and review some areas that have scored below standard in recent
•Presenters today are:
• Rhonda Borders, LCSW, Quality Specialist
• Maggie Tilley, Compliance Officer
Era of Health Care Reform
• Today’s providers work in an atmosphere of
increasing regulation and review.
• More and more audits of state Medicaid programs,
hospitals and facilities, and individual providers, some
with multi-million dollar paybacks, are occurring
around the nation.
• Documentation requirements for Medicaid are more
detailed and extensive than for other insurance
ValueOptions-Colorado Role
• ValueOptions and its partner BHOs hold the
Medicaid contract with the State of Colorado.
• VO is responsible for quality review and for
identifying and reducing issues of fraud, waste, and
• We rely on State and Federal Medicaid rules for
paying claims and auditing files.
•ValueOptions is ramping up quality reviews,
compliance audits, and claims verification to avoid
significant negative consequences when a federal
audit occurs in Colorado.
Documentation and Claims
•Documentation in the medical record is the only
evidence of your work.
•Documentation must be well done according to
standards to support the claim that you make for
•Payments are made for a medically necessary
covered service provided to an eligible individual by
a qualified provider.
Medicaid Standards
• Revised standards went into effect for any new
enrollment of a beneficiary after 1-1-12.
• Previous training last year explained the standards.
• That webinar is still available on your BHO website
under Provider Information.
• You will also find a set of suggested forms on those
websites that may be helpful to you.
– You are not required to use our forms.
Recent Audits
• About 70 records of independent providers have
been reviewed since May, 2012.
• Reviews done for all three BHOs.
• Average scores in the 5 areas monitored remain
below the 80% minimum.
• Some providers received passing scores.
Administrative Area
•Medicaid Client Rights & Responsibilities Form.
– The client/parent/gdn should sign this page at
– See the suggested forms. It includes information
about Advance Directives and Well-Child Exams that
a provider should also cover with a new client.
•CCAR—Colorado Division of Behavioral Health
requires a CCAR for each Medicaid client at
admission, at annual update, and at discharge.
– The CCAR can be submitted on line at the VO-CO
Assessment Area
• Many assessments need a little more detail:
– Description of the problem
– Mental Status exam
– Psychiatric and substance abuse history of primary
family members
• Culture/Values/Beliefs:
– Not only a statement of ethnicity, religion, or values,
but also HOW they potentially will affect the
therapeutic relationship or the nature of therapeutic
Clinical Formulation
• A short paragraph that explains your analysis of
the assessment.
• Justifies medical necessity by summarizing client
symptoms & matching them to the DSM-IV criteria
• States client’s willingness and ability to actively
participate in treatment
• Names initial goals and interventions until there is a
formal treatment plan in place.
• Includes anticipated Length of Stay.
Treatment Plans
• Improvements can be made by including:
– Discharge goal—How much change is necessary before it
would be appropriate to discharge?
– Measurable objectives to address goals
• more than “increase” or “decrease”—how much
change is enough?
• depends on detail of symptom frequency and impact
• reasonable and achievable in the # of authorized
• fit client’s developmental level and capacities
– Therapist’s interventions—more than “individual” or “family”
– Parent involvement in child’s treatment—what will they do?
– Signatures AND a progress note that says you developed
plan with client
Progress Notes Elements
• Each note must stand alone.
• Elements must be present for each session.
• Place of Service is most often missing (such as office,
home, school, community)
• Also…
Date of service
Start and end time
CPT code or service type
Persons present
Diagnosis being treated
Clinician signature AND date of signature
Progress Note Content
• Focus on the clinically important aspects of the session.
• Notes should include:
• which goal from the tx plan is being addressed in session
•specific interventions used by therapist
•the client response to session
•client progress toward goals.
• Avoid “daily report” progress note.
•Do not include significant detail about what client said or did unless it
is relevant .
Coordination of Care
• Coordination among providers is important to
prevent duplication of services.
•Chart should show documentation of”
– Routine letter to PCP: enrollment, dx and meds
– Record of consultation with other providers or resources:
teacher, pastor, caseworker, etc.
– Referral to medical care (& f/U) if no physical in the last
Audit Process-Clinical
• Approach is educational
• First audit—educational letter and re-audit
• Second audit—educational letter and request for
Corrective Action Plan (CAP)
• Third audit—referral to Quality of Care Committee
• Potential removal from the network
Audit Process - Claims
• Four claims per record are audited on 15 elements,
– current treatment plan
– tx plan signatures
– elements of the progress note
• Auditor sends claim report to Compliance Officer
who decides on further action, as needed.
– Education or recoupment possible
– Responds in a separate letter
Questions & Answers
• Rhonda Borders, LCSW, Quality Specialist
– 719-580-2010
– [email protected]com
• Maggie Tilley, Compliance Officer
– 719-538-1435
– [email protected]
•Tom Dahlberg, LPC, Quality Specialist
– 719-538-4698
– [email protected]