Download Basic Training in Medi-Cal Documentation

Basic Training in Medi-Cal Documentation
Sara Kashing, J.D.
Staff Attorney
The Therapist
May/June 2012
Since 1998, Medi-Cal mental health services have been provided through county-based Mental
Health Plans (“MHPs”). Although counties have their own specific forms, policies and
procedures for following Department of Mental Health protocols for Medi-Cal reimbursements,
there are some key concepts regarding clinical assessments, client recovery plans, and
progress notes that every county mental health provider should keep in mind when completing
Medi-Cal related paperwork.
This article is intended to serve as a basic training for therapists who provide mental health
services through county MHPs.
Background on the Consolidation of Medi-Cal Mental Health Services
As a result of statutory and regulatory changes occurring from 1995 to 1998, Medi-Cal funded
mental health services that were once provided through fee-for-service- Medi-Cal1 and County
Medi-Cal Short Doyle programs2 are now provided through a managed care system. The
counties act as the local mental health plans.3
MHPs are responsible for the delivery and authorization of services. Although major changes
are likely to occur throughout 2012, the Department of Mental Health (“DMH”) is currently
responsible for oversight and implementation of services.4
County MHP services are for adults who have chronic and severe psychiatric disabilities. They
also target children under age 21 who need mental health treatment services.
County mental health plans are responsible for providing all specialty mental health Medi-Cal
services to Medi-Cal eligible individuals who have a covered diagnosis and who meet the
eligibility criteria in state regulations.
Clinicians who wish to successfully navigate the Medi-Cal system should be familiar with four
main aspects of Medi-Cal documentation: The Clinical Assessment, Medical Necessity, The
Treatment Plan and Progress Notes.
Clinical Assessment
Purpose of the Clinical Assessment
A patient’s mental health assessment serves a multitude of purposes. The primary purpose of
the assessment, however, is to help the clinician and the treatment team to understand and
describe the nature of the patient’s mental health problems and to create an appropriate
treatment plan. The assessment also serves as the source of information which is used to
document the patient’s eligibility for services under the Medi-Cal program.
Regulatory, or Medi-Cal imposed, objectives include determining whether a covered diagnosis
is present and making sure the assessment information supports the diagnosis.
To conduct a thorough client assessment the following areas should be covered:

Nature of the presenting problem

History of the present illness

Previous psychiatric history

Developmental, family and social history (required for minors)

Medical history

Mental status examination (including risk assessment)

Five-axis diagnosis
Always keep in mind that the assessment should be updated when additional information
becomes available and/or the clinical picture changes significantly enough so that the initial
assessment is no longer consistent with the current treatment.
Completing the Clinical Assessment
All sections and items must be completed for the assessment to be considered adequate. This
means that a clinician should enter “N/A” if the item is somehow not applicable or “N/AV” if the
information is not available. In general, checking “none” or “no problem” eliminates the need for
a written entry for that item, whereas checking that some aspect of the item is present does
require a written explanation if space for writing is provided.
A clinician’s ultimate goal is to produce a Clinical Assessment that describes the client in depth
and comprehensively, provides a good symptomatic and historical basis for a DSM-IV
diagnosis, and illustrates any present medical necessity. (NOTE: Treatment is considered
“medically necessary” when the patient has a primary diagnosis that is eligible for
reimbursement, the patient’s life functioning is impaired, the treatment is intended to address
the impairment and there is a reasonable likelihood that the treatment will benefit the patient.
“Medical necessity” will be reviewed in greater detail further in the article.)
When recording a client’s presenting problem, practitioners should be sure to include
information about when the presenting problem began and what behaviors or circumstances led
to the need for the present assessment. In other words, clinicians should ask their clients to
describe any problems or relevant conditions affecting their physical health and mental status.
Typically, this will involve a discussion about any difficulties clients are having with functioning
on a daily basis. For example, some clients may report that they are having difficulty meeting
their responsibilities, carrying on social relations or managing their living arrangements and
health. It is critical that the description of the presenting problem supports the diagnosis.
In all cases, a risk assessment must be conducted. This risk assessment includes asking clients
about their risk of committing suicide and/or homicide. Information about the frequency of
suicidal and/or homicidal thoughts and methods should be gathered. Clinicians should also ask
whether their clients are at risk of experiencing abuse or victimization. If any current risks exist,
clinicians should address the risks with appropriate follow-up through continued assessment,
the treatment plan, and interdisciplinary notes. Notes should include any actions taken, and any
recommendations and/or referrals given in response to the assessed risks.
Examples of risks that would need to be addressed include the following:

Client states want to hurt self or others

Client alleges abuse requiring a mandated report

Client mentions medical risks such as pregnancy
Any cultural information which seems relevant to a client’s treatment should always be entered
because understanding a client’s cultural background is often times necessary in order to
provide effective care. Cultural issues that are relevant to an assessment include, but are not
limited to:

Client Identity (How does the client see himself/herself in regard to race, ethnicity, sexual
orientation, religion, color, and disability group?)

Language (What language is the client fluent and literate in? Does the client have a
language preference?)
When assessing a client’s mental status, clinicians should gather information necessary for
determining a client’s thought process (i.e., what is the client’s general quality and adequacy of
understanding, reasoning and planning?). A clinician should determine whether a client is
having any type of delusions or hallucinations. A client’s mood should also be taken into
account and recorded as part of the assessment process.
An assessment of how the symptoms of a mental disorder impair functioning must be
documented. Clinicians should clearly document when a daily dysfunction that justified services
for the client is present. Finally, it is critical that clinicians document any dispositional actions
that have been taken. Such dispositional actions might include referral to another clinic,
individual or group therapy, or day treatment. Any recommendations or other community
referrals given to the client or family should also be carefully documented.
Medical Necessity
In order to successfully navigate the Medi-Cal system, it is necessary for a clinician to
understand the nature of services provided under Medi-Cal and the criteria that are utilized to
determine whether a person is eligible to receive such services. Because all services provided
under Medi-Cal must be “medically necessary” it is important that clinicians understand the
meaning of medical necessity and be able to document the treatments being provided to
patients in the Medi-Cal program as being medically necessary.
Medical Necessity Defined
Treatment is considered “medically necessary” under the Medi-Cal guidelines when the
following components are present:

The patient must have a primary diagnosis which is eligible for reimbursement under
Medi-Cal. Most Axis I diagnoses qualify.

The patient’s life functioning must be impaired as a result of the psychiatric condition.

The recommended treatment must be intended to address the identified impairment in
functioning.

There must be a reasonable likelihood that the recommended treatment will be
beneficial to the patient (i.e., that it will have an identifiable positive impact on the
patient’s identified problems).
Therefore, when making a determination as to whether the criteria have been met, practitioners
should consider the following issues:

Does the client have a listed Axis I DSM-IV diagnosis?5

Does the client meet at least one of the impairment-related criteria?

Does the recommended treatment address the identified impairment?

Is there a reasonable likelihood that the treatment will be beneficial to the patient?
Medical Necessity Covered and Non-Covered Diagnoses
Most Axis I DSM-IV diagnoses are included. The following is a list of diagnoses that are covered
and accepted as principal diagnoses:

Pervasive Developmental Disorders, except Autistic Disorders

Disruptive Behavior and Attention Deficit Disorders

Feeding and Eating Disorders of Infancy and Childhood

Elimination Disorders

Other Disorders of Infancy, Childhood, or Adolescence
Schizophrenia and other Psychotic Disorders, except Psychotic Disorders due to a
general medical condition

Mood Disorders, except Mood Disorders due to a general medical condition

Anxiety Disorders, except Anxiety Disorders due to a general medical condition

Somatoform Disorders

Factitious Disorders

Dissociative Disorders

Paraphilias

Gender Identity Disorder

Eating Disorders

Impulse Control Disorders not classified elsewhere

Adjustment Disorders

Personality Disorders, excluding Antisocial Personality Disorder

Medication-Included Movement Disorders, if related to other included diagnoses6
The following is a list of diagnoses that are not covered or accepted as principal diagnoses:

Mental Retardation

Learning Disorders

Motor Skills Disorder

Communication Disorders

Autistic Disorder

Tic Disorder

Delirium, Dementia, and Amnestic and other Cognitive Disorders

Mental Disorders Due to a general medical condition not classified elsewhere
Substance-Related Disorders

Sexual Dysfunctions

Sleep Disorders

Antisocial Personality Disorder

Psychological Factors affecting a medical condition

Adverse Effects of Medication NOS

Relational Problems (V-Codes)

Problems related to abuse or neglect (V-Codes and others)

Additional conditions that may be a focus of clinical attention (V-Codes and others)
Medical Necessity Required Impairments and Required Interventions
The severity of the psychiatric disability is also relevant to determining when the medical
necessity criteria have been met.7 The regulations at Cal. Code Regs Title 9 §1830.205(b)(2)
state that a person must have at least one of the following impairments as a result of a mental
disorder/diagnosis:

A significant impairment in an important area of life functioning.

A reasonable probability of significant deterioration in an important area of life
functioning (i.e., a reasonable probability a child will not progress developmentally as
individually appropriate).8
Another important issue to consider when determining the presence of a medical necessity is
whether the medical definition for MHP services is met. The “intervention criteria” are set out in
subsection (b)(3). Cal. Code Regs. Title 9 §1830.205(b)(3) stating that a person must meet
each of the intervention criteria listed below:

The focus of the proposed intervention must be to address the condition or
impairment(s) resulting from the covered diagnosis.

The expectation is that the proposed intervention will significantly diminish the
impairment, prevent significant deterioration in an important area of life functioning, or
allow the child to progress developmentally as individually appropriate.9
Treatment Plan
What the Plan Should Cover
The treatment plan, which is required for all services, must be written every 12 months and
include the following:

Specifies the goals for treatment

Describes the services to be provided to the client

Provides documentation of client participation in treatment planning

Serves as a vehicle for review of certain services
Because the client plan drives services to clients, the plan must contain specific, observable,
quantifiable goals, as well as proposed types of interventions, and proposed timeframes for the
interventions. The goals listed in the plan should be related to community functioning and
require services. In exceptional circumstances, if a service other than an Assessment, Crisis
Intervention and/or Plan Development is provided during the intake period, before completion of
the client recovery plan, clinicians should document the service to demonstrate its medical
necessity. In other words, the Diagnosis Sheet must include a covered diagnosis and the
gathered assessment information should be sufficient to support that diagnosis; the impairments
must be adequately described and be significant enough to justify the service before the intake
is completed; the planned intervention should address the impairment condition; and show that
the client had input into the provision of the intervention and was in agreement with the
intervention. There should be no periods of care without an operative Client Recovery Plan, with
the exception of the intake period if services do not go beyond the intake period.
Completing the Plan
The treatment objectives must be based upon the client diagnosis-dysfunction condition.
Diagnostic symptoms should reflect the predominant symptoms, consistent with the assessment
data, and contributory to the functional impairments for the client. Observable, measurable,
functional impairments should be listed and operationally defined. The impairments should be
individually based and represent how diagnostic symptoms present themselves in
observable/measurable behavioral events or episodes. The following are examples of
measurable objectives:

“Will reduce arguing and noncompliance with adult directives from 12 times per week to
three times per week for four consecutive weeks by teacher and parent report by June
30, 2009.”

“Will reduce suicidal ideations/gestures from seven times per week to a goal of zero
times per week and sustain for six months as measured by self/caregiver report and
provider observation. To be achieved by June 30, 2009.”

“Reduce concentration difficulties (i.e. careless mistakes, failure to listen, failure to
complete homework, losing pencils or books to complete tasks, leaving or squirming in
seat) from ten times a day to five times a day and sustain for three months, by parent
and teacher report by June 30, 2009.”
Progress Notes
Definition and Purpose of Progress Notes
The Progress Note is a narrative record of the following:

Face-to-face client contact

Phone calls

Interactions with collateral contacts

Other events that are relative to treatment
Progress Notes provide evidence of the patient’s need or the “medical necessity” for treatment
at a particular point in time. In California, treatment programs or clinics that receive funding from
the state Medi-Cal program are routinely visited by utilization-review staff whose job is to review
treatment records, including progress notes, for documentation of medical necessity. In order to
be Medi-Cal billable, the progress note must relate to the client’s mental health condition and
covered diagnosis.
Furthermore, although there are no specific legal and ethical standards that dictate the form or
content of a progress note, there are relevant legal and ethical standards that are applicable to
clinical record-keeping in general. For example, California law requires therapists to maintain a
record of treatment that would be typical of other, reasonable and prudent therapists.10 Ethical
standards provided and enforced by professional associations such as CAMFT are also a
source of guidance to therapists concerning issues of recordkeeping. The CAMFT Code of
Ethics, section 3.2, states the following: “Marriage and family therapists maintain patient
records, whether written, taped, computerized, or stored in any other medium, consistent with
sound clinical practice.”
Content of Progress Notes
Every note should contain a description of the client’s current condition, the problem or
dysfunction being addressed during the session, provider interventions, and the client’s
response to the interventions. On occasion, a description of where the client stands in the
overall course of treatment is also appropriate because linking the interventions to the diagnosis
and measurable objectives indicated on the Client Plan is good practice.
Reimbursable and Non-reimbursable Notes
Interventions described in the progress notes need to address a principal covered diagnosis.
Progress notes which focus on interventions for a secondary or Axis II excluded diagnosis (i.e.,
substance-related disorders or mental retardation) would result in a negative coverage
determination in the event of an audit.
US Health Care Industry’s Upgrade to Claim Form 5010 and the Transition to ICD-10 for
Diagnosis
As of January 2012, all HIPAA covered entities are required to use Version 5010 claim forms.
This means that any electronic transaction must now be submitted using Version 5010 versus
the old Version 4010/4010A forms. Any electronic transactions that do not use Version 5010
claim forms are not HIPAA compliant and will be rejected. For those clinicians who were
unaware of this fairly new requirement, it is important to note that with respect to providers who
either work with insurance and/or clearinghouses, it is highly likely that this requirement has
already been met. If you are concerned about whether you are doing what is required, check
with the entities you are working with to determine whether you are in compliance.
In late 2013, HIPAA covered entities will be expected to have transitioned to ICD-10 for medical
diagnosis and inpatient procedures coding. For behavioral health diagnosis this change will
consist of a switch from numeric codes of three to five digits to alpha numeric codes of five to
seven digits which will give a diagnosis higher specificity. Given that this requirement will not go
into effect until October 1, 2013, there is no immediate need for therapists to do anything
different at this time.
For more information about Version 5010 claim forms or the transition to ICD-10 for diagnosis,
please visit Centers for Medicare & Medicaid Services at www.cms.org. CAMFT will also be
providing more information to members about the transition to ICD-10 as the 2013 deadline
approaches.
Sara Kashing, JD, is a staff attorney for CAMFT. Sara is available to answer member calls
regarding business, legal, and ethical issues.
References
1.
Primarily acute psychiatric hospital care, outpatient psychiatrist, and psychological visits.
2.
In 1972 Welf. & Inst. Code § 14021 was amended to add Short-Doyle community mental health services to the scope of
benefits under the Medi-Cal program. The result was the development of the Short-Doyle/Medi-Cal (SD/MC) program in
addition to the Fee-For-Service Medi-Cal (FFS/MC) program for mental health services. The SD/MC program provided
cost-based reimbursement for a broad range of mental health services and a limited range of services for treatment of
substance abuse. These mental health services are provided by the county directly or through providers which contract
with the county. The FFS/MC program provided reimbursement for a comprehensive range of health services and a
limited range of mental health services. Services are reimbursed on a fee-for-service basis, or within managed care
contracts. These mental health FFS/MC services were provided primarily by private hospitals and private practitioners.
3.
The authorizing Welf. & Inst. Code §§5775-5780 and 14680-14685. Medi-Cal funded services are often provided by
entities that are contracted with County Mental Health.
4.
Some of Medi-Cal mental health functions currently performed by DMH are to be transferred to the Department of Health
Care Services by July 1, 2012. Those functions include: Medi-Cal Program Compliance, County Medi-Cal Program
Technical Assistance, IT Support for Medi-Cal Systems and Subsystems,Data Management and Support for Medi-Cal
Program, Medi-Cal Program and Policy Support, and Administrative and Financial Services in Support of the Medi-Cal
Program.
5.
DSM-IV refers to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (1994), published by the
American Psychiatric Association, Washington D.C.
6.
Title 9, Section 1830.205
7.
The severity criteria can be found in subsection (b)(2) of the regulation.
8.
For purposes of this section, a child is a person under the age of 21 years old.
9.
Id.
10. California Business and Professions Code §§ 4982(v); 4992.3(s).