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The fastest way for me to learn something new is by looking at examples. If you learn the same way I do, the information presented here should help you get the hang of documenting your work and assisting with the development of treatment plans. There are also materials available for download from the links on the lower left.

 

HOT OFF THE PRESS:

02/22/21: Updated Assessment & CP. Version 022221 adds prompt for tobacco use on p.2.

12/30/20: Use 90899-110 for work done on initial treatment plans after 60 days of enrollment. We can only use 90899-6 during the first 60 days. Any work done on initial treatment plans past the 60-day limit should be coded as non-compliant (90899-110). This is true even if the client was MIA during all or most of their first 60 days. This rule does not apply to significant revisions that need to be made in an existing initial treatment plan due to changes in a client's diagnosis, level of functioning, life situation, etc.

11/29/20: New code, Collateral (90899-157), added to links on the left. Use this code when providing education and training to significant support persons in the member's life (family members, R&B managers, etc.). These services can be done with or without the member.

10/23/20: "How to Be a Good Tenant" - New set of example interventions added under Rehab > IADLs.

10/07/20: Case managment monitoring (90899-1). A monitoring service is basically a re-assessment. Instead of performing the services identified on the treatment plan, you’re devoting the session to collecting more information about the member. This kind of service makes sense when you have reason to believe there have been significant changes that could affect the course of treatment. If a member has just been discharged from the hospital, for example, or hasn’t been seen for several months, it’s probably a good idea to sit down with them and re-assess their needs. If you’ve been providing rehab services for several months, you might want to spend a session reviewing progress the member has made and talking about what’s working and what isn’t. But under normal circumstances, monitoring services shouldn't be necessary more than once every couple months. If you’re doing them more often than that, check with your Team Lead to see if your time can be used more effectively.

10/07/20: To graduate from our program and move to a lower level of care, members need to be able to perform basic tasks without our assistance. If a member is with you and needs to schedule an appointment with their PCP, use the call as an opportunity to teach the member necessary skills (90899-17) rather than making the call for them (90899-1). If you've accompanied them to a doctors appointment, coach them through the check-in process rather than doing it yourself. This won’t be possible in every case, but it’s something you should try to do as often as you can. Sooner or later members will have to learn these skills, so we want to start teaching them as early as possible.

02/17/20: Starting April 1st, we'll begin using a single form for all Assessments and Care Plans. There will no longer be one form for the Initial and another for the Annual -- they'll all be done on the same form. The new form is available for download on the lower left ("Assessment & CP 040220" in blue).

08/27/19: The MSE and Diagnosis pages of the Initial and Annual Assessment must now be completed by an LPHA. Both forms have been revised to allow for that. You'll no longer be initialing and corner-dating these pages. If you're assisting with an assessment, be sure to download the latest version of the form from the links on the left (v. 040220).

12/10/18: Quick review of footnotes we're currently using (examples):

NFTF=Calling 911 while another PSC stayed with the member
TT=Driving alone between TAO and member's home
NBTT=Transporting member from her home to SSA and back
Note: Travel time divided between 2 services I did at this location
Note: There is no travel time on this note as I provided a billable service in the car.

Footnotes are only required on billable notes, but some teams choose to add the "travel time divided" and "TT" footnotes to both the billable and non-billable notes for a given location because it helps make things clearer. Check with your Team Lead to find out what their preferences are.

All PHI has been de-identified per HIPAA Privacy Rule