Examples of 90899-6 notes

 

TCPs (now referred to as Care Plans or simply "CP") can take several days to complete, and may therefore be documented in a number of different ways. Below are examples of how the process looks when spread over 3 days, as well as cases in which the plan was completed in single day. Single-day plans can be tricky to document since you can't drop multiple notes on the same person, at the same location, with the same billing code, on the same date. Below you'll see at least one way it can be done correctly.

Three-day

Meeting 1:

G:  Rose is a 55 y/o single Caucasian female.  I met with Rose at her B&C today to begin work on her Annual A&P (Re-assessment and Care Plan) and to complete associated documentation.

I:  Reviewed Rose's prior objectives with her.  She had 2 objectives on her last recovery plan:  Objective #1 was to be able to "utilize 3 new coping skills that help her manage her anxiety."  She successfully met this objective.  Objective #2 was to volunteer at an animal shelter.  Rose reports she was "not quite up to doing this" due to anxiety around others, transportation issues, and limited capacity for physical labor.  I gathered information necessary to complete her Annual Re-assessment and Care Plan. Engaged her in a discussion of her hopes and dreams, her strengths, and her perception of the barriers she needs to overcome.  Helped her prioritize her needs and discussed provisional objectives. Completed SNAP, Risk Assessments, and Multnomah Scale.  Updated/added PHI releases.

R:  Rose was engaged in the process of discussing new objectives and was receptive to this writer's questions.  

P:  I will develop Rose's CP based on the information obtained today, and present it to Rose for her approval and signature next week.

An Initial (60-day) Care Plan would obviously not include a review of prior objectives.

 

Meeting 2:

G:  Rose is a 55 y/o single Caucasian female.  This note is to account for time I spent completing Rose's Annual Re-assessment and Care Plan due 12/1/12.

I:  Completed Re-assessment and CP based on information obtained during a face-to-face meeting with Rose on 11/16/12 and information contained in her chart.  Significant issues that were discussed during the 11/16 meeting were Rose's need to better manage her anxiety, her need to be involved in fulfilling activities, and her need to remain safely housed when she is experiencing an increase in symptoms.  Objectives based on those needs and on discussions with the member were incorporated into the CP writer developed today. 

R:  Rose was not present for today's service.

P:  Plan is to present the completed CP to Rose this week for her approval and make any changes she feels are necessary.

 

Meeting 3:

G:  Rose is a 55 y/o single Caucasian female.  This note is to account for time I spent reviewing Rose's CP with her and obtaining her signature.

I:  Met with Rose at TAO clinic and reviewed her new Care Plan.  Went over objectives with Rose to ensure she understood them, and that they accurately reflected her wants and needs.  Rose said they did, and signed her completed Care Plan.

R:  Rose was cooperative and engaged.

P:  Plan for next service is to begin working with Rose on Objective #2.

 

Single-day

Once in a while you'll have to do an entire A&P in a single day.  Below is an example of how it looks on paper.  There are between 4-5 hours of billable time in these examples – keep that in mind when dropping other notes on the same day.

For client in the field (2 notes):

Note 1:   90899-6   F2F=58    Service=58    Doc=9    Travel=24   LOC: Private Residence (times are just examples)

G:  Yolanda is a 35 y/o single Hispanic female whose CP is due October 1st.  This note is to account for 2 face-to-face services:  1) Meeting with Yolanda at her R&B to review her prior objectives, create new ones, and obtain information necessary complete her Annual A&P; and 2) meeting with Yolanda at her R&B later in the day to complete associated documentation and obtain her signature on the new Care Plan.

I1:  Reviewed Yolanda's prior objectives with her.  She had 2 objectives on her last Care Plan:  Objective #1 was to be able to describe 3 techniques she could use to manage her temper.  She was able to describe 4 and successfully met this objective.  Objective #2 was to volunteer in the community at least 4 hours a week.  Yolanda was unable to accomplish this because, in her words, "I was just too distracted by all the problems I'm having with my family."  Engaged Yolanda in a discussion of her hopes and dreams, her strengths, and her perception of the barriers she needs to overcome.  Helped Yolanda prioritize her needs and create new objectives.

I2:  Met with Yolanda a second time, later in the day, to review the completed Care Plan. Completed SNAP, Risk Assessments, and Multnomah Scale.  Updated/added PHI releases. Obtained Yolanda's signature on the completed Care Plan.

R:  Yolanda was cooperative and friendly.  

P:  Plan is to meet with Yolanda next week to begin working on Objective #1. 

Note:  Travel time consists of 2 round-trips from TAO to client's residence, with T/W alone in the car.

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Note 2:   90899-6   F2F=0    Service=203    Doc=3    Travel=0   LOC: Clinic

G:  Yolanda is a 35 y/o single Hispanic female.  This note is to account for time I spent completing Yolanda's Annual A&P at TAO clinic after meeting with her this morning at her R&B.

I:  Completed Annual Re-assessment and Care Plan (A&P) based on information obtained during a face-to-face meeting with Yolanda earlier today (see separate note). 

R:  Yolanda was not present for this portion of today's service.

P:  Will present the completed Care Plan to Yolanda later today to obtain her approval and signature.

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Client in the clinic with service time under 2 hours (one note):

Documented with a single note   90899-6   F2F=119    Service=119    Doc=8    Travel=0   LOC: Clinic

G:  Yolanda is a 35 y/o single Hispanic female whose Annual CP is due October 1st.  I met with Yolanda at TAO Program today to develop her A&P (Re-assessment and Care Plan) and complete associated documentation.

I:  Reviewed Yolanda's prior objectives with her.  She had 2 objectives on her last CP:  Objective #1 was to be able to describe 3 techniques she could use to manage her temper.  She was able to describe 4 and successfully met this objective.  Objective #2 was to volunteer in the community at least 4 hours a week.  Yolanda was unable to accomplish this because, in her words, "I was just too distracted by all the problems I'm having with my family."  Completed CFS.  Completed SNAP, Risk Assessments, and Multnomah Scale.  Updated/added PHI releases. Engaged Yolanda in a discussion of her hopes and dreams, her strengths, and her perception of the barriers she needs to overcome.  Helped Yolanda prioritize her needs and create new objectives.  Obtained Yolanda's signature on the updated CP.

R:  Yolanda was guarded at the beginning of the meeting but was able to relax and get involved in creating her new objectives.

P:  Plan is to meet with Yolanda next week to begin working on Objective #1.

Note:  Unless you have a laptop and printer you can take out into the field, this note can only be used for a service at the clinic.

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Client in the clinic with service time over 2 hours (one note):

Documented with a single note   90899-6   F2F=58    Service=261    Doc=11    Travel=0   LOC: Clinic

G:  Yolanda is a 35 y/o single Hispanic female whose Annual Care Plan is due October 1st.  This note is to account for 3 services:  1) Meeting with Yolanda to review her prior objectives, create new ones, and obtain information necessary to update her CP; 2) developing the CP without Yolanda present; and 3) meeting with Yolanda later in the day to complete associated documentation and obtain her signature on the new Care Plan.

I1:  (F2F) Reviewed Yolanda's prior objectives with her.  She had 2 objectives on her last CP:  Objective #1 was to be able to describe 3 techniques she could use to manage her temper.  She was able to describe 4 and successfully met this objective.  Objective #2 was to volunteer in the community at least 4 hours a week.  Yolanda was unable to accomplish this because, in her words, "I was just too distracted by all the problems I'm having with my family."  Completed CFS.  Engaged Yolanda in a discussion of her hopes and dreams, her strengths, and her perception of the barriers she needs to overcome.  Helped Yolanda prioritize her needs and create new objectives.

I2:  (Non-F2F) Developed Yolanda's Annual A&P based on information obtained during the face-to-face meeting noted above. 

I3:  (F2F) Met with Yolanda a second time, later in the day, to review the completed Care Plan. Completed SNAP, Risk Assessments, and Multnomah Scale.  Updated/added PHI releases. Yolanda signed her completed CP.

R:  Yolanda was cooperative and friendly.  

P:  Plan is to meet with Yolanda next week to begin working on Objective #1.

Note:  The issue here is, we don't want to give the impression we made the client sit in front of us for 3 or 4 hours while we did their A&P. That's too long to ask someone to sit at our desks and in most cases there's no need for them to do so. There's nothing magic about "2 hours" -- it isn't a rule, just a suggested cut-off point for F2F time in a single service.

All PHI has been de-identifed per HIPAA Privacy Rule