Category Archives: Service Notes
We think too much; thus we fail to act. That’s what Hamlet was saying during his “To be or not to be” soliloquy, right? To live or not to live? Should you bear the painful burden of life or to refuse the burden by killing yourself?
Or does the fear of the unknown (death) make us bear our painful lives? (Although Shakespeare was much more eloquent).
Medicaid providers, how many times have you reviewed your own documentation only to find accidental scrivener’s errors? The service note failed to denote the correct date of service (DOS)…the Physician’s Authorization and Certification for Treatment (PACT) form cited an incorrect Medicaid number…or the CPT code on a service incorrectly indicated an individual treatment when the service was clearly a group treatment. (People, we are NOT talking about forgery or altering dates of a physician’s signature…these things would be considered FRAUD. We are merely talking about scrivener’s or clerical errors).
To revise or not to revise…that is the question!
And what an important question it is. Because, so easily, innocent documentation corrections could transmute into documentation fraud. Medicaid fraud. Criminal investigations. Bad!
A recent Office of Administrative Hearings (OAH) decision gives us some guidance on when to revise or when not to revise.
St. Mary’s Home Care Services, Inc. v. NC Division of Medical Assistance (DMA) Finance Management Section Audit Unit NC DHHS was signed January 8, 2014, by Administrative Law Judge Beecher Gray, who was recently appointed as a Special Superior Court Judge. Believe me, we will miss Judge Gray at OAH. His Order in St. Mary’s Home Care was his parting good-bye.
In St. Mary’s Home Care, the Department was seeking a recoupment of $4,334,056.09. One of the reasons for the recoupment was that the Department contended that St. Mary’s had violated “best practices” in the way it had amended PACT forms and service notes.
A witness for the Department testified that “best practices” required St. Mary’s to either create a new document or to strike through the corrected portion, enter the correction, sign the name of the individual making the correction, and append an explanation for the correction to the document.
Judge Gray disagrees.
“The Agency’s misunderstanding of the policy and use of unpublished “best practices” as a justification for its decision is erroneous, in violation of rule and law, exceeds the Agency’s authority, and is arbitrary and capricious.”
“The Agency failed to meet its burden of proving St. Mary’s violated clinical coverage policy when it made changes or corrections to PACT form plans of care.”
So when should you NOT revise?
Obviously, do not commit fraud. But, according to St. Mary’s Home Care, slight revisions to PACT forms and service notes will not be enough to warrant an overpayment.
“Go, bid the soldiers shoot.”
This tip, Tip #6, is devoted to Outpatient Behavioral Health providers.
Outpatient Behavioral Health providers are licensed psychologists or psychologists who provide mental health counseling to Medicaid recipients.In light of the recent mass murder in Connecticut, I believe that most people would agree that the ability for anyone to receive mental health services is of utmost importance. In my opinion, mental health services are the most needed and most under-used health care service. In the debate between guns and violent video games, I say that mental health issues and mental health care services trump both. Create a society in which mental illnesses are (not necessarily accepted) but not stigmatized, people are comfortable asking for help regarding mental illnesses, people can identify others who are in need of counseling, and all people, no matter their insurance coverage, have access to mental health care services. Create this society and this society equals violent crimes under control. A society in which a gun is merely a gun. For hunting, protection of family, or sport…not a weapon of mass destruction. Mental health awareness is the key.
Ok, enough of my soap box.
In North Carolina, Outpatient Behavioral Health providers are bound by NC DMA Clinical Coverage Policy No. 8C. Policy No. 8C is much shorter in length than most clinical policies. It’s terseness is a thing of beauty for the Outpatient Behavioral Health providers.
Herein lies tip #6:
Because 8C is so short, so terse, all Outpatient Behavioral Health providers should print off Policy No. 8C and fasten it onto the walls of the office (at least the meaty portions…not the beginning and ending fluff).
Outpatient Behavioral Health providers should have Policy 8C memorized. Outpatient Behavioral Health providers should dream about Policy 8C. Outpatient Behavioral Health providers should be able to regurgitate the meat of Policy 8C …..I mean, come on, people, Policy 8C is 31 pages. Without the fluff (just the meat) Policy 8C is only, in my opinion, 10 pages of meat…10 pages (pages 7-17)!!!! If the Outpatient Behavioral Health providers memorize a mere 10 pages, the Outpatient Behavioral Health providers will be able to thwart potential reconsideration reviews. Even if the State threatens or begins a reconsideration review, if the Outpatient Behavioral Health providers have memorized these 10 meaty pages, the Outpatient Behavioral Health providers will easily be able to defend the reconsideration review based on documentation and, thus, avoid any alleged overpayments. (After page 17 is important to follow in practice: it consists of billing codes and revisions to past policies, but 17-31 is not the “meat” regulating Outpatient Behavioral Health providers).
For this blog, I am concentrating on Section 7.3.3. Section 7.3.3 is, by far, the biggest reason Outpatient Behavioral Health providers get dinged in Medicaid audits….BY FAR. Service notes….really? YES.
Service notes are detail-oriented. Tedious. And one mistake on a service note…I mean a SMALL mistake…will cause the State to attempt to recoup the Medicaid payment bestowed for the entire service rendered. For example, an Outpatient Behavioral Health provider gets prior authorization from the correct state-contracted entity , a valid referral by a Carolina ACCESS primary care physician, a signed consent by the Medicaid recipient, a regulatory-correct Comprehension Clinical Assessment, a valid Treatment Plan and Service Plan… BUT….on the service note for one day…one couseling session….forgets to describe the Medicaid recipient’s reaction to the counseling. Or forgets to put the duration of the session (writes 6pm, but forgets to write that the session ended at 7pm). Or forgets to describe the nonverbal journal-writing session and bills for the play treatment (a higher-reimbursable code). What happens? A Medicaid audit.
According to Policy 8C, there must be a progress note for each treatment encounter that includes the following information (And, people, this is NOT difficult. This is the minimum and easy to meet):
- Date of service;
- Name of the service provided (e.g., Outpatient Therapy – Individual/Family Tx);
- Type of contact (face-to-face, phone call, collateral); non-face-to-face services are not covered and not reimbursable;
- Purpose of the contact (tied to the specific goals in the Tx plan);
- Description of the treatment or interventions performed. Treatment and interventions must include active engagement of the individual and relate to the goals and strategies outlined on the individual’s plan;
- Effectiveness of the intervention(s) and the beneficiary’s response or progress toward goal(s);
- The duration of the service (e.g., length of the assessment or treatment in minutes; Pharmacological Management does not require documentation of the duration of service); and
- Signature, with credentials, degree, and licensure of clinician who provided the service. Electronic signatures must adhere to DMA guidelines. A handwritten note requires a handwritten signature; however, the credentials, degree, and licensure may be typed, printed, or stamped.
- Service notes must be written in such a way that there is substance, efficacy, and value. Interventions, treatment, and supports must all address the goal(s) listed in the plan. They must be written in a meaningful way so that the notes collectively outline the beneficiary’s response to treatment, interventions, and supports in a sequential, logical, and easy-to-follow manner over the course of service.
Is this difficult? No. Not rocket science. I suggest creating a template. The template should have a space for every required component of the service note. Print off hundreds…no thousands. Keep the print-offs in a location that all employees, if present, know of and make them understand that every service note must adhere to the template. Completely. No short-cuts. No…”I forgot.” Follow the template.
The result? The Department of Health and Human Services (DHHS) or any of its entities or contracted companies will be able to audit any service note, written by any employee or you, and say, “This Outpatient Behavioral Health provider has met the minimum requirements of Policy 8C; therefore, there is no reason to try to recoup Medicaid funds from this provider. This provider has followed the rules.”
Wow. Shock and awe. Could that happen? Yes: MEMORIZE THE MEATY 10 PAGES OF POLICY 8C!!!!! And you too could avoid Medicaid recoupments.