Non-billable services (90899-5)
When we do a service that isn't medically necessary, it usually meets the definition of non-billable case management (90899-5). These services aren't billable to Medi-Cal so they don't need to be written in GIRP format. A simple narrative, as shown in the examples below, is usually enough. Be sure to include information about where you started, what you did, and where you finished so reviewers can determine whether the times you report are reasonable.
The first 4 examples are notes written by new CMs who were shadowing a more experienced worker.
James is a 43 y/o divorced Caucasian male who is enrolled in TAO due to a need for intensive mental health services. James is assigned to my team. I accompanied James's CM to meet with him today to introduce myself, learn more about James and his situation, and provide support as needed. After meeting with James at his R&B, I returned to TAO.
Sarah is a 34 y/o single Hispanic female diagnosed with schizoaffective disorder. Sarah is enrolled in TAO as a result of her need for intensive mental health services. She is assigned to my team. I accompanied Sarah’s CM on a home visit today in order to introduce myself to Sarah and learn more about her current needs, treatment objectives, and progress towards long-term goals. Returned to TAO afterwards.
DeShawn is a 25 y/o single African American male. DeShawn is diagnosed with paranoid schizophrenia. His A/H, paranoia, and trouble concentrating impair his ability to maintain social interaction and manage his mental illness. DeShawn is assigned to my team. I accompanied his CM on a home visit today to meet DeShawn, introduce myself, and become more familiar with his case. After the meeting with DeShawn I returned to TAO.
Yolanda is a 31 y/o single Mexican female. She is receiving services from TAO due to her need for intensive mental health services and is assigned to my team. I accompanied Yolanda's CM on a home visit today to meet Yolanda and learn more about her goals, treatment, and current needs. During our home visit, Yolanda discussed problems she is having with one of the other residents at her R&B and her anxiety over taking the bus. After meeting with Yolanda I returned to TAO.
CMs providing transportation. Be sure to say where you started and finished so reviewers can determine whether your travel times are reasonable.
Emma is a 33 y/o single Filipino female who has an appointment with her psychiatrist at TAO today. This note is to account for 2 round trips I made from TAO to Emma's R&B -- the first to pick her up for her appointment, the second to take her home afterwards.
Frank is a 51 y/o single African American male. Frank wants to go to the food bank today and I agreed to give him a ride. I drove from TAO to Frank's home, picked him up, and took him to the food bank. Helped him pick out items and load them into my car. I took Frank home afterwards then returned to TAO.
Rosa is a 56 y/o separated Hispanic female. This note is to account for time I spent driving from TAO to Rosa's R&B, assisting her with moving her belongings from Neptune House R&B to her new Section 8 apartment, then returning to TAO afterwards.
Other common non-billable services
Sam is a 52 y/o single Caucasian male. I drove from TAO to Sam's apartment to meet with him today, but he did not answer the door. His windows were open so I called his name several times in addition to knocking on the door, but there was no response so I returned to TAO. Sam has no phone. Plan is to follow up with Sam and attempt to get him to agree to be seen on a particular day of the week, or specific time, to facilitate face-to-face visits.
Carol is a 43 y/o separated Caucasian female who is currently homeless and living in her car. I drove from TAO to State College Blvd. & Katella Ave. today attempting to meet with her, as this is where she reports that she usually parks. I was not able to find her near this intersection, or by the tracks north of this intersection where she said she would be. Plan is to continue looking for Carol in the areas above, and by calling her emergency contact if necessary.
Member is a 48 y/o single Hispanic male who is due for his bi-weekly Risperdal Consta injection. I called member's R&B twice today attempting to remind him, but no one answered the phone. I left 2 messages on his voicemail reminding him of the need to come in and get his injection today or tomorrow (4/18/19 or 4/19/19).
Donald is a 34 y/o single Native American male. Telecare is his rep payee. I met with Donald at TAO today and assisted him with obtaining $75 cash from TAO Business Office to pay monthly rent on his storage locker, and a second payment (check) as his P&I.
Wait-time note. Notes like this are common for locations like SSA and the DMV, where you spend some time doing a billable service but a lot of time waiting also. Since wait time isn't billable it has to be separated out into a separate note.
Janette is a 47 y/o divorced Caucasian female. I accompanied Janette to SSA today to help her resolve issues regarding a suspension in her SSDI benefits (see separate billable note). This note is to account for time I spent waiting in the lobby before meeting with an SSA representative and performing no billable services.
Note: Travel time divided between 2 services I provided at this location.