Helping clients with Common Ground can be documented and billed in several different ways. It depends on what the client's needs are, what you do and say, and how your intervention is reflected in the progress note you write. Here are some examples:
As non-billable case management (90899-5):
Frank is a 34 y/o single Hispanic male. I reminded Frank to log onto Common Ground before his appointment and complete his CG Health Report. I told him to let me know if he needed any help. I checked on Frank 5 minutes later and observed him successfully navigating through the CG website.
As targeted case management (90899-1):
G: Brenda is a 41 y/o single Caucasian female. Brenda would like to get a job, but due to lack of self-confidence and low self-esteem, she is reluctant to apply.
I: I linked Brenda to Common Ground video resources, specifically the two videos where peers discuss their experiences getting a job. I assisted Brenda with accessing Common Ground as she lacks computer experience. This service was necessary to increase Brenda's independence in the community and build her self-esteem and self-confidence.
R: Brenda able to view the videos independently.
P: Will continue providing assistance with accessing Common Ground until Brenda is able to use the system on her own.
Note: No time was billed for Brenda's independent work on the computer.
As rehab (90899-17):
G: Jamal is a 24 y/o single African American male. Last year Jamal got a job at Costco, but due to A/H he had trouble staying focused and remembering his job duties, and was let go after 3 months. Jamal now reports feeling hopeless about life in general and is convinced no one will ever hire him.
I: I met with Jamal prior to his psychiatric appointment to help him navigate and complete the CG Heath Report in hopes that it would amplify Jamal's current thoughts and feelings to his doctor. Completion of the CG Report revealed that Jamal was having thoughts of self-harm. I assessed and contracting for safety, then worked to instill hope by reviewing and discussing a CG Recovery Video of a peer who had found gainful employment. I helped Jamal improve wellness skills by reviewing his CG Personal Medicine with him (things he does to be well) and teaching him about other forms of Personal Medicine he might like. Jamal's completed CG Report linked him to Personal Medicine Cards that can help him manage his distressful symptoms. I prompted Jamal to pick the two cards he liked best, then printed them out and encouraged him to use them on a daily basis.
R: Jamal was distracted and talked to himself frequently throughout our session. He appeared to be responding to A/H but said he was not. He required frequent redirection to stay on topic and his answers were mostly restricted to yes and no.
P: Will continue working with Jamal on increasing his motivation and self-esteem, and improving the quality of communication he has with his doctor.
As medication support (90899-8, for nurses):
G: Binh is a 42 y/o single Vietnamese female. During a routine nursing screening today, Binh gave conflicting answers about the medications she was taking and suggested she had quit taking at least one of her meds. Binh has a history of discontinuing meds on her own, without informing her recovery team or consulting with her doctor, and this often leads to relapse and hospitalization.
I: I helped Binh log on to Common Ground and complete a self-report. I reviewed with Binh her 11 responses to "How I feel about my medications." Binh reported that her Zyprexa was making her drowsy and causing her to gain weight, and that she had begun skipping doses because of side-effects. I introduced Binh to the CG tool “Medication Decision Log” and explained that it can help her make the best decision she can about her medications. I prompted her to complete the Decision Log and bring it with her when she comes in next week, so that it can be reviewed by members of her recovery team. Binh agreed and was willing to continue taking her Zyprexa until she completes the log and meets with a team member. She also agreed to talk with her doctor about her medication concerns. I notified the doctor about Binh’s concerns and prompted the doctor to review Binh's CG Health Report with her. I also notified Binh's team and asked them to review her Medication Decision Log with her next week.
R: At times it appeared as if Binh might be RTIS but she denied this. Her mood brightened when the Decision Log was introduced and she thanked me several times.
P: Plan is to follow-up with Binh's doctor and recovery team and intervene as necessary.