Services in the Car

There's nothing wrong with doing services in your car, as long as it's safe and makes sense to do them there. You obviously can't teach someone to prepare a meal or wash clothes. But it's a good place to practice social skills, brainstorm ideas, come up with plans, and help members prepare for places you're taking them (group outings, job interviews, etc.). It can also be a good time to get to know someone after a warm hand-off. Services in the car are a little trickier to document than services in the clinic or at the client's home, but once you get the hang of it they aren't that hard.

 

When I was a PSC, a trick I learned was just to document the service as if it took place at the clinic, then go back and add a few key phrases. I'd start with something like this:

G: Larry is a 44 y/o single Hispanic male. Due to irritability and low tolerance for frustration, Larry gets into loud arguments with his neighbors over minor issues such as the volume of their music. He pounds on shared walls and yells profanity at them through their windows. His apartment manager has given him warnings and says he will be asked to leave if his behavior continues.

I: Brainstormed with Larry about alternative ways of handling issues with his neighbors. We came up with 4 ideas: 1) Establish a good relationship with his neighbors before problems come up. Offer a friendly greeting, smile, introduce himself, and make small talk if the opportunity presents itself. Neighbors who know Larry in this way are more likely to be responsive to his requests than neighbors who don't; 2) Ask neighbors to turn the volume down politely, by going to their door, saying excuse me, and making his request in a non-threatening manner; 3) When volume levels are high, use that time to run errands, visit friends, go jogging (which Larry likes doing), or do another activity that takes him away from the apartments; 4) Talk to his apartment manager about it. That's what the manager is there for.

Then I'd add the phrases you see in red below:

G: Larry is a 44 y/o single Hispanic male. Due to irritability and low tolerance for frustration, Larry gets into loud arguments with his neighbors over minor issues such as the volume of their music. He pounds on shared walls and yells profanity at them through their windows. His apartment manager has given him warnings and says he will be asked to leave if his behavior continues. I gave Larry a ride to TAO today for P&I, and used the drive as an opportunity to help him come up with solutions to this problem.

I: On the drive to TAO, brainstormed with Larry about alternative ways of handling issues with his neighbors. We came up with 4 ideas: 1) Establish a good relationship with his neighbors before problems come up. Offer a friendly greeting, smile, introduce himself, and make small talk if the opportunity presents itself. Neighbors who know Larry in this way are more likely to be responsive to his requests than neighbors who don't; 2) Ask neighbors to turn the volume down politely, by going to their door, saying excuse me, and making his request in a non-threatening manner; 3) When volume levels are high, use that time to run errands, visit friends, go jogging (which Larry likes doing), or do another activity that takes him away from the apartments; 4) Talk to his apartment manager about it. That's what the manager is there for.

TT: Driving alone from TAO to member's apartment.
Note: There is no NBTT on this note as I provided a billable service in the car.

The service above is billed as 90899-17. Time I spent driving to the member's house alone is billable travel time (TT). The drive back to TAO, with the member in my car, is accounted for as F2F/Service time.

 

 

 

If your service continues after you leave the car, or starts before you get into it, break it up so reviewers can see what you did and where, like this:

I: Met with Roberto at his R&B and gave him a ride to the event. On the way there, I role-played with Roberto to help him practice interacting with others.  Reviewed relaxation techniques Roberto can use at the event, such as deep breathing, progressive relaxation, and positive/reassuring mental imagery. At the awards, I modeled appropriate behavior when interacting with others and encouraged Roberto to initiate conversations with persons around him. Asked him open-ended questions in front of the group at our table to provide easy entry points and encouraged him to elaborate on interesting things he had said. Provided subtle prompts and feedback. Assured Roberto that he was doing well in order to reduce his anxiety. On the drive back to Roberto’s R&B, I praised Roberto for his efforts and reviewed with him what he felt he had learned today.

TT: Driving alone between TAO to Roberto's R&B.
Note: There is no NBTT on this note as I provided a billable service in the car.

 

 

 

Another in-car rehab service (90899-17) continuing through the destination and back into the car again:

I: Met with Chris at his apartment and took him to the dentist's office. On the drive to the dentist's office, I reviewed with Chris the self-interventions he can use if he starts getting upset or frustrated, such as focusing all his attention on his breathing and breathing slowly and deeply, using calming mental imagery, and signaling if he needs a time-out to calm down or ask questions. At the dentists, I sat with Chris during his procedure and provided support. I explained what was happening and prompted Chris to use the skills we had practiced on the way here. I did this repeatedly towards the end of the procedure as the hygienist was inexperienced and began making mistakes. On the drive back to Chris's home, I worked to increase his ability to put himself in in other people's shoes, with the goal of reducing angry outbursts. Pointed out that the hygienist was new and probably very nervous, and asked Chris to think about how he might feel in that situation, and how it might affect his performance.

TT: Driving alone between TAO and Chris's apartment.
Note: There is no NBTT on this note as I provided a billable service in the car.

 

 

 

CMS monitoring (90899-1) after a warm hand-off, while taking the member home, then at his home. The drive back to the clinic alone is billable travel time:

I: On the drive to Dennis’s home, I asked him questions about himself, how he is adjusting to his new R&B, if he has been utilizing any of the anxiety-reduction techniques he has been learning and if so, which ones seem to help; if he has made any friends yet (one of his current goals); if he is encountering any barriers that affect his ability to access treatment; and if he has been able to take his medications as directed (also a current goal). After we arrived at his R&B I continued monitoring his progress. Dennis shared that he was still having trouble remembering to take his medications, and that the wall calendar system proposed in his CP wasn’t working for him. He identified "keeping myself busy" as the coping skill he had been utilizing that seemed to work best for controlling his anxiety, but said he was having trouble coming up with things to do.

TT: Driving alone from Dennis's R&B back to TAO.
Note: There is no NBTT on this note as I provided a billable service in the car.

 

 

 

All PHI has been de-identified per HIPAA Privacy Rule