Clinical Documentation
Improvement Boot Camp
RCPA Conference
October 8, 2014
Agenda
 Behavioral Health Services Cultural Overview
 Current Regulatory Environment – New Compliance Challenges
 Function of the Progress Note
 Defensive Maneuvers – Audit Proof Documentation
– Technical Basics
– Medical Necessity
– Standard of Care
 Offensive Maneuvers – Moving Forward
– EMR Issues
– DSM-5/ICD-10-CM Transition
 Field Training Exercise - Mock Audits
2
Boot Camp Begins
Behavioral Health Services
CULTURAL OVERVIEW
Cultural Overview
 Historically, behavioral health services have been isolated and
managed separately from other medical disciplines;
 Behavioral health services are “carved out” from medical health
insurance plans and most often managed by a separate company
with different rules.
 Long-standing differences in coverage between behavioral health
and medical benefits.
 Behavioral health services are less understood than other medical
specialties and often viewed as a “little different” and medicine’s
“stepchild.”
 Neglect by parent organizations of their behavioral health programs;
 Audit and Compliance programs have traditionally not looked
“under the hood” until a governmental audit occurs.
5
Cultural Overview
 Historical lack of evidence based treatment interventions with
measurable outcomes; traditional treatment focused on the patientprovider relationship.
 Translates into poorly worded, overgeneralized and un-measurable
treatment goals for patients.
 Difficulty measuring progress and defending medical necessity.
 High emphasis on confidentiality results in suboptimal documentation to
support services rendered:
 How much to document?
 Where to document?
 What can be shared under HIPAA?
6
Cultural Overview
 Practitioner independence to practice in their own way:
 Lack of consistency among practitioners translated into variable
documentation styles and language.
 Difficulty for third party entities to interpret/understand
treatment rendered and assess if medical necessity met.
 Behavioral health providers have largely not been targeted by
major governmental entities resulting in complacency in
documentation.
 Providers not being held accountable for documentation.
7
Cultural Overview
 Practitioner resistance to financial implications, “but we’re here to help
people.”
 Not understanding documentation’s link to reimbursement.
 Liability issues may not be as heightened as in a medical model.
 Decreased lack of attention to documentation and continuity of the
overall patient medical record.
8
Cultural Overview
 Separation between mental health and substance abuse
services;
 Differences in licensing and accreditation standards.
 Differing approaches to treatment.
 Differing standards for staff qualifications.
9
Cultural Overview
Impact on Medical Necessity
 While medical necessity is not new for inpatient/Partial Hospitalization
Programs (“PHP”), it is a relatively new concept for outpatient services.
 In the 80’s, services were available to whomever could access and wanted
them; patient/client/consumer motivation was key criteria.
 Challenge of providing services for those who may not understand need for
services, i.e., documenting medical necessity for involuntary treatment.
 Mental health services have served a protective function for patients who
may have not met traditional criteria for medical necessity; challenge of
defending through documentation , role of social issues as safety
issues.
10
Current Regulatory Environment:
A Changing Landscape
New Compliance Challenges
 Overhaul of CPT psychiatric codes;
 Effective January 1, 2013
 Roll-out of DSM-5;
 Introduced May 2013
 Transition to ICD-10;
 October 1, 2015
 Transition to the Electronic Health Record
12
Overhaul of CPT Psychiatry Codes
 Most significant change is physician shift to Evaluation & Management
(“E&M”) codes;
 Elimination of the long standing pharmacologic management CPT
code 90862 which contained general documentation requirements.
 E&M codes requires specific documentation requirements, for
which psychiatrists in outpatient settings in particular are not
accustomed to utilizing.
13
Office of Inspector General - 2014 Work Plan
“We will determine the extent to which selected payments for
evaluation and management (E/M) services were inappropriate. We
will also review multiple E/M services associated with the same
providers and beneficiaries to determine the extent to which
electronic or paper medical records had documentation
vulnerabilities. Context—Medicare contractors have noted an
increased frequency of medical records with identical
documentation across services. Medicare requires providers to
select the billing code for the service on the basis of the content of
the service and to have documentation to support the level of
service reported. “
14
Getting Down to Basics:
The Progress Note
15
Function of the Progress Note
 Invoice for Services Rendered
 Is the only “proof” of what occurred in treatment and what
services were delivered; to whom, by whom, why, for how
long, whether it was effective and whether it should be
reimbursed.
 Justifies the purpose of the service; supports medical
necessity.
16
Function of the Progress Note
 Communication Tool
 Documentation needs to be sufficiently clear and detailed to
enable another practitioner to take over the case for any number
of reasons.
 Documentation needs to be readily understood by a third party
entity who may/may not have knowledge of behavioral health.
17
Function of the Progress Note
 Standard of Care

In the event of negligence, Standards of Care (“SOC”) will be the
measuring tool for determining whether a practitioner was negligent.

A SOC holds a person of exceptional skill or knowledge to a duty of
acting as would a reasonable and prudent person possessing the same
or similar skills or knowledge under the same or similar circumstances.

SOC include Practice Acts, state and federal laws, accreditation
agencies, professional associations, scientific literature and/or specific
organizational standards.
18
Defensive Maneuvers for Compliant
Documentation:
Making Your Progress Notes Audit-Proof
19
Defensive Maneuvers
20
Defensive Maneuvers
Strategic Tactics
1. Technical Basics
2. Support medical necessity
3. Standard of Care
21
Strategic Tactic #1
Technical Basics
22
Technical Basics
 Compliance is not an option
 Know regulatory and organizational policies for
documentation and billing:
 Timed codes; includes “rounding” rules
 Unit limits
 Non-reimbursable services
23
Technical Basics
 Write legibly and ensure legible, written signature with credentials.
 Alternatively, ensure timely, electronic signature authentication of
documentation.
 Do not attempt to alter the record. Ensure that the original and the
correction/addition are clearly and correctly marked.
 Small errors – single line drawn through the error with initial and
date.
 Correction of previous entry – begin a new entry with corrected
content with current date and time.
 Appropriate process to correct entries in the EMR
24
Technical Basics
 Be concise and “smart” in documenting; more is not necessarily
better.
 Use lay language and ensure acronyms are spelled out; records
may be reviewed by others with little/no behavioral health
background and will need to readily understand the content.
 Using templates for progress notes may increase efficiency but
inherently contribute to compliance risks to include lack of
patient specificity, boxes/lines left blank and /or inadequate
documentation.
25
Technical Basics
 Remain mindful of content that becomes standard/pre-populated
on each progress note; always read your note and edit
appropriately.
 Consider the potential reader audiences of your notes; other
clinicians, supervisory staff, utilization reviewers, insurance
companies, the client and/or client family, significant other(s),
plaintiff attorneys and/or exhibit in a court proceeding.
26
Strategic Tactic #2
Support Medical Necessity
27
Medical Necessity
Initial Evaluation
 Support for medical necessity begins with the initial evaluation resulting
in a diagnoses as the primary focus of treatment and the individual’s
capacity to participate in treatment, development of an individualized
treatment plan, progress notes that address the patient/client progress
relative to the treatment goals and establishing a discharge plan from
day one.
 There must be continuity between these components; disjointed record
conveys lack of direction in treatment and invites questions about
medical necessity.
28
Medical Necessity
Treatment Plan
 Diagnostic formulation from the initial evaluation drives treatment
direction articulated in the individualized treatment plan.
 Practitioners often view negatively and underestimate the significance
of the treatment plan.
 Behavioral health providers will be held increasingly accountable for
measurable outcomes; incorporating evidence based practices when
possible and articulating them in the treatment plan will support medical
necessity.
29
Medical Necessity
Treatment Plan
•
Establish long and short term goals that are easily understood,
concrete, measurable and obtainable so that progress can be
demonstrated. Unrealistic goals set patient/client up to appear as
having failed and medical necessity of intervention(s) more likely
questioned.
•
Avoid use of stock, repetitive goals from client to client; i.e.
“stabilization of mood,” “improved social functioning,” “absence of risk,”
“normalization of functioning.”
•
Update goals regularly or when interventions appear ineffective.
30
Medical Necessity
Progress Notes
 Clinical notes for therapy sessions serve to document not only
the patient’s clinical status and progress, but also serve to
ensure that quality of care is adequate and payment is made for
services provided. Progress notes should include:
 Date and length of the therapy sessions; start/stop times.
 Patient's current clinical status as it relates to diagnosis;
current symptoms and functional status.
31
Medical Necessity
Progress Notes
 Content of the therapy session, i.e., note of the major themes
discussed.
 Summary of the therapeutic intervention of the session; be specific.
 Summary assessment of the patient's progress or lack of progress
toward the treatment goals. KNOW THE TREATMENT PLAN.
 Plan for the immediate future; connect back to the treatment plan.
32
Medical Necessity
HIPAA and Psychotherapy Notes
 Psychotherapy notes are notes recorded (in any medium) by a
health care provider who is a mental health professional
documenting or analyzing the contents of conversation during a
private counseling session or a group, joint, or family counseling
session and that are separated from the rest of the individual’s
medical record.
 Psychotherapy notes excludes medication prescription and
monitoring, counseling session start and stop times, the modalities
and frequencies of treatment furnished, results of clinical tests, and
any summary of the following items: diagnosis, functional status,
the treatment plan, symptoms, prognosis, and progress to date.
33
Strategic Tactic #3
Standard of Care
34
Standard of Care
 Documentation needs to reflect that your actions were similar to what
reasonable clinicians would do under the same or similar
circumstances; what would a comparable peer social worker,
psychologist, licensed counselor, nurse have done.
 More important to document details of decisions that increase risk
rather than those that decrease risk; i.e. documenting a decision to
hospitalize may not require as lengthy an assessment versus allowing
the patient to return to an unsupervised, unmonitored setting which
required more comprehensive evaluation.
 Health care providers have a duty to be familiar with SOCs – ignorance
is not a defense.
35
Standard of Care
 Medical record will be the only defense regarding whether professional
specialty specific standards of care were followed.
 Mistake in judgment does not necessarily violate SOCs. Important to
document a reasonable and complete thought process and clinical
considerations, in addition to the final decision.
 Include both positive and negative, verbatim responses from the client.
36
Offensive Maneuvers
37
Moving Forward – EMR Design
 Ensure EMR documentation templates will capture required
regulatory information.
 All entries into the medical record must be unambiguously
identified and authenticated by their author.
 Be aware of default information in templates and/or cut and
paste functions.
• Failure to appropriately edit records, challenges
documentation integrity and credibility of the information.
38
Moving Forward – DSM-5/ICD-10
 DSM-5 maps to ICD-9 & ICD-10.
 Full use of DSM-5 projected by October 1, 2015 when ICD-10-
CM is adopted as our standard coding system.
 Dates when DSM-IV may no longer be used will be determined
by the American Psychiatric Association.
• Handout “DSM-5/ICD-10 Overview for Behavioral
Health Providers”
39
Field Training Exercises - FTX
Break – Out Groups for
Mock Documentation Audits
40
Resources
American Psychiatric Association
http://www.psych.org/
American Academy of Child and Adolescent Psychiatry
http://www.aacap.org/
American Psychological Association
http://www.apa.org/
National Association of Social Workers
http://www.naswdc.org/
American Association for Marriage and Family Therapists
http://www.aamft.org/iMIS15/AAMFT/
American Counseling Association
http://www.counseling.org/
Judge David L. Bazelon Center for Mental Health Law
http://csmh.umaryland.edu/
41
Boot Camp Instructors
– Georgia Rackley, MSN, RN, CPC, CLNC, Senior Clinical
Specialist
• georgiarackley@sunstoneconsulting.com
• 717-574 -1947
– Laura Ehrlich, RN, BSN, CCM, Senior Consultant
• lauraehrlich@sunstoneconsulting.com
• 717-968 – 5035
www.sunstoneconsulting.com
42