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Carf Clinical Forms Diagnostic Assessment document sample
Document Sample
SOQIC Forms Compliance Grids
Reasons for the Compliance Grids
One of the planned outcomes for the SOQIC initiative was to ensure that completed clinical forms would allow a provider to successfully
meet the clinical documentation requirements of the major accreditors; Joint Commission (TJC), Commission on Accreditation of
Rehabilitation Facilities (CARF) and Council on Accreditation (COA), as well as the documentation requirements of the major payers for
community mental health services in the State of Ohio: Medicaid, ODMH, ODADAS and Medicare.
Generally, clinical documentation is looked at by:
• Accreditors for evidence that agency policies and procedures related to documentation and clinical care of the client are being
followed and are resulting in quality care and positive clinical outcomes.
• Payers to determine if the documentation justifies payment for the services provided, and if the clinical care described in the
documentation meets their standards for service quality, which are embedded in their regulatory requirements.
Compliance grids were originally developed by the SOQIC Compliance Review Team as a way to monitor development of the SOQIC
clinical forms. The grids list every element on each form and identify which payers and/or accreditors requires the information contained
in that field for clinical documentation purposes.
How to Interpret Compliance Grids
The grids are intended as a tool to give provider agencies an understanding of the purpose of many of the fields on the SOQIC forms.
There is a grid for each SOQIC form with billable services. Each grid lists every field on the form and cites, if applicable, the particular
regulation, rule or standard or Medicaid, ODMH, ODADAS, and/or the accreditors that applies to that field. (Note: MCD/CARE =
Medicaid/Medicare)
To use the compliance grid:
1. Locate the grid for the form you are interested in. The form name appears in upper left corner.
2. Read down the left side of the form to find the Element field.
3. Read across to find the citation in the Ohio Administrative Code Rule (state payer requirements) and the number of the
Accreditation Issues, if any.
4. Read the MCD/CARE Requirements section to determine if the field/element is a primary source (P) or supporting source (s).
Primary source (P) is likely to be used by an auditor as a primary source of information to support medical necessity, active
participation and/or client benefit.
Secondary source (s) provides supporting information regarding medical necessity, active participation and/or client benefit.
5. Read the Comments relating to the field/element.
TABLE OF CONTENTS
Compliance Grid for Ohio SOQIC Forms
Adult Diagnostic Assessment ………….………………………………………………… 1
Adult Diagnostic Assessment Update…………………………………………………… 28
Child/Adolescent Diagnostic Assessment……………………………………………….. 35
Child/Adolescent Diagnostic Assessment Update………………………………………. 60
Initial Psychiatric Evaluation……………………………………………………………….. 66
Crisis Intervention Assessment and Plan………………………………………………... 77
Individualized Service Plan…………………………………………………………………. 84
Individualized Service Plan Review…………………………………………………..…… 91
Psychiatric/Pharmacological Management Plan…………………………………………. 95
Pharmacologic Management/Psychiatric Progress Note……………………………….. 99
Partial Hospital Progress Note……………………………………………………………… 104
Pharmacologic/Nursing Progress Note (Long Version)………………………………..… 111
Group Progress Note………………………………………………………………………… 115
Individual Progress Note…………………………………………………………………….. 120
Community Psychiatric Supportive Treatment Progress Note (Short Version)……….. 126
Transfer/Discharge Summary………………………………………………………………. 130
Compliance Grid for Ohio SOQIC Forms
Adult Diagnostic Assessment
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
3793:2-1-
5101:3-27 5122-29-04
08
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
All payers require that the client be
identified. Also National
Accreditors all require sufficient
identifying information. Best
1 practice requires that the name or
client number or both of the
individual appear at the top of
IM.6.2 every page in case the record
Client Name (First, MI, Last Yes 06-F1 0 becomes disassembled.
Use of an ID number would allow
2 the PHI to be de-identified as
Client No. 06-F1 defined by HIPAA.
National accreditors don't list
CRI2.0 information needed specifically in
3;DTX presenting problem or in
3 PC.2.1 3.02;F diagnostic overall, but want info
0;PC.2 PS3.0 gathered as determined by the
.70; 3;MH2 provider and as appropriate and
Presenting Problem- with cues to IM.6.2 .01;PS necessary to assist in assessment
assist in documentation (B)(1)b 08-K-3a 0 R2.02 2.B.9 P and treatment planning.
4 Date of Admission 2.G.3
PC.2.1
0;PC.2 * Note: For this element field,
.60;PC 5122-29-04(B)(1)(e) lists the
5
.2. 70; Asses- elements to be included when
Living Situation-Type(with multiple IM.6.2 sment clinically indicated, as determined
alternatives) (B)(1)(e)v* 0 Matrix by the provider.
PC.2.1
0;PC.2 * Note: For this element field,
.60;PC 5122-29-04(B)(1)(e) lists the
6
Living Situation-Household .2.70; Asses- elements to be included when
members/age/quality of IM.6.2 sment clinically indicated, as determined
relationship (B)(1)(e)xxiv* 0 Matrix 2.B.9 by the provider.
1
Adult Diagnostic Assessment
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
3793:2-1-
5101:3-27 5122-29-04
08
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
PC.2.1
0;PC.2 * Note: For this element field,
.60;PC 5122-29-04(B)(1)(e) lists the
7
Living Situation-Significant Family .2.70; Asses- elements to be included when
Members/Others not listed IM.6.2 sment clinically indicated, as determined
above/relationship/age (B)(1)(e)xxiv* 0 Matrix 2.B.9 by the provider.
* Note: For this element field,
5122-29-04(B)(1)(e) lists the
elements to be included when
clinically indicated, as determined
by the provider.
Accreditors want an assessment of
8
natural supports, which include
family, marital and significant other
PC.2.1 relationships. Strong natural
0;PC.2 supports are also seen as critical
.60;PC for reducing the amount and length
.2.70; Asses- of community agency supports,
Primary Family/Marital/Significant IM.6.2 sment including mental health, for clients
Other Support Systems (B)(1)(e)xxiv* 08-K-3l 0 Matrix 2.B.9 and families.
* Note: For this element field,
5122-29-04(B)(1)(e) lists the
elements to be included when
clinically indicated, as determined
by the provider.
History of familial behavioral health
9 problems may impact the
diagnostic decisions made by
PC.2.1 clinical/medical staff and may also
0;PC.2 impact treatment decisions
.60;PC especially those that require
.2.70; Asses- interventions and support by family
Pertinent Family History; including IM.6.2 sment members to keep clients in lower
family MH and AoD history (B)(1)(e)xxiv* 08-K-3l 0 Matrix 2.B.9 P levels of care.
2
Adult Diagnostic Assessment
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
3793:2-1-
5101:3-27 5122-29-04
08
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
* Note: For this element field,
5122-29-4(B)(1)(e) lists the
elements to be included when
clinically indicated, as determined
by the provider.
Rehabilitation option services and
recovery-based programming
should be built on the strengths
10
and capabilities of the client.
Interventions built on strengths can
result in earlier successes and
shorter and less expensive
interventions. COA as well as
other accreditors require strengths
PC.2.1 assessments for special need
0;PC.2 populations. If strengths can be
.70; Asses- used to build solutions and skills,
Strengths/Capabilities/(Weak- IM.6.2 sment 2.B.9c, they should be considered in
nesses: ODADAS only) (B)(1)(e)xxiii* 08-K-3o; p 0 Matrix e s s treatment planning.
3
Adult Diagnostic Assessment
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
3793:2-1-
5101:3-27 5122-29-04
08
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
* Note: For this element field,
5122-29-04(B)(1)(e) lists the
elements to be included when
clinically indicated, as determined
by the provider.
Any limitations should be
considered in determining the
Skills Deficits/Skills
Training/Community Support
Needs on page 7 of the Diagnostic
11
Assessment and should be
evaluated for inclusion in the
treatment plan. Services directed
toward reduction in these
limitations, if they are caused by or
result from the mental illness and if
PC.2.1 they interfere with the client's
0;PC.2 ability to stay in the community or
.70; Asses- move to a higher level of
Limitations of Activities of Daily (B)(1)(e)xxi; IM.6.2 sment 2.B.9. functioning or recovery, make a
Living xxii* 08-K-3p 0 Matrix d,l P strong case for medical necessity.
* Note: For this element field,
5122-29-4(B)(1)(e) lists the
elements to be included when
clinically indicated, as determined
by the provider.
COA and CARF are very
interested in an assessment of
12
natural supports which include
friends, social and peer supports.
These supports are expected to
substitute for some or all mental
health provider services over time.
Asses- 2.B.9. The use of natural supports is a
Friendship/Social/Peer Support PC.2.6 sment m7;2. key concept in recovery-based
Relationships (B)(1)(e)xxiv* 0 Matrix B.9.p service delivery systems.
* Note: For this element field,
5122-29-4(B)(1)(e) lists the
13 PC.2.6 Asses- elements to be included when
0;PC.2 sment clinically indicated, as determined
Meaningful Activities (B)(1)(e)vi* .70 Matrix 2.B.9 s by the provider.
4
Adult Diagnostic Assessment
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
3793:2-1-
5101:3-27 5122-29-04
08
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
* Note: For this element field,
5122-29-04(B)(1)(e) lists the
elements to be included when
clinically indicated, as determined
14 by the provider.
PC.2.1 For substance abusing clients, this
0;PC.2 may be their primary recovery
.60;PC Asses- program. For MH clients peer
.2.70; sment supports may be a significant
Community Supports/Self Help IM.6.2 Matrix; 2.B.9. component of their recovery plan
Groups (AA,NA,NAMIO,etc.) (B)(1)(e)x* 08-K-3d 0 RPM7 m,p s s and a source of social supports.
* Note: For this element field,
5122-29-04(B)(1)(e) lists the
elements to be included when
clinically indicated, as determined
by the provider.
JCAHO specifically requires an
15 assessment of religion an spiritual
orientation if the client is being
PC.2.6 treated for addictions. The
0;PC.2 Asses- assessment should include
.70; sment information on how spirituality
PC.3.1 Matrix; 2.B.9. impacts the client's recovery from
Religion/Spirituality (B)(1)(e)xxv* 08-K-3n 00 RPM7 n mental illness.
RPM7;
CM3.0
5;CRI2
16 PC.2.6 .03;DT
0;PC.2 X3.04;
.70; MH2.0 DMH specifically requires an
Cultural/Ethnic IM.6.2 3;PSR 2.B.9. assessment of multicultural/ethnic
Issues/Information/Concerns (B)(1)a 0 2.04 n influences.
* Note: For this element field,
5122-29-04(B)(1)(e) lists the
elements to be included when
clinically indicated, as determined
17 PC.2.6 by the provider.
0;PC.2 If the adult client is dually
.70; Asses- diagnosed MI/MRDD the JCAHO
IM.6.2 sment 2.B.7. also require this information under
Developmental Issues (B)(1)(e)i* 0 Matrix a PC.3.40; PC.3.50
5
Adult Diagnostic Assessment
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
3793:2-1-
5101:3-27 5122-29-04
08
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
* Note: For this element field,
5122-29-04(B)(1)(e) lists the
PC.2.6 elements to be included when
0;PC.2 clinically indicated, as determined
18 .70; by the provider.
IM.6.2 The accreditors would like this
0; Asses- area explored because information
PC.3.1 sment 2.B.9. may be essential to recovery or
Sexual History/Concerns (B)(1)(e)xi* 08-K-3m 0 Matrix n treatment.
* Note: For this element field,
5122-29-04(B)(1)(e) lists the
elements to be included when
clinically indicated, as determined
by the provider.
May indicate learning difficulties
19
that will have to be considered in
developing community support
services, especially skill building in
both adults and children. JCAHO
requires detail in PC.3.40 if client
Asses- is positive in this area. CARF
PC.2.9 sment standard requires exploration of
Education History checklist (B)(1)(e)xiv* 08-K-3h 0 Matrix 2.B.9.s educational functioning.
* Note: For this element field,
5122-29-04(B)(1)(e) lists the
elements to be included when
clinically indicated, as determined
20 by the provider.
May indicate learning difficulties
Asses- that will have to be considered in
PC.2.9 sment skill building in both adults and
History of Learning Difficulties (B)(1)(e)xviii* 08-K-3h 0 Matrix 2.B.9.s children. See above also.
6
Adult Diagnostic Assessment
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
3793:2-1-
5101:3-27 5122-29-04
08
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
* Note: For this element field,
5122-29-04(B)(1)(e) lists the
elements to be included when
21 clinically indicated, as determined
by the provider.
Asses- Medicaid requires if it is MH
PC.2.9 sment related. See also below under
Barriers to Learning (B)(1)(e)xviiii* 0 Matrix 2.B.9.s P P special communication.
* Note: For this element field,
5122-29-04(B)(1)(e) lists the
elements to be included when
clinically indicated, as determined
by the provider.
This is especially critical if the
provider intends to bill this service
under the interactive CPT codes. If
client has dementia or another
impairment that impedes their
ability to communicate this must
be noted. If the client is unable to
22
communicate in any manner,
Medicare and Medicaid will likely
not pay for the service. Their ability
to communicate may also impact
their ability to benefit from
treatment. With Medicaid
communication difficulties may
increase the length of time for a
service and therefore the charge
for the service. CARF standards
require this assessment to
Asses- determine if assisted technology is
Special Communication Needs: PC.2.7 sment 2.B.9. needed in the provision of
with descriptors (B)(1)(e)xxi* 0 Matrix q P P P services.
7
Adult Diagnostic Assessment
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
3793:2-1-
5101:3-27 5122-29-04
08
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
* Note: For this element field,
5122-29-04(B)(1)(e) lists the
elements to be included when
clinically indicated, as determined
by the provider.
23 Accreditors request general
employment information. May be
important to determine if client is
eligible for pre-employment
Employment checklist re: amount Asses- services under community support
and type of employment/Not in PC.2.8 sment 2.B.9. or needs referral to employment
Labor Force (B)(1)(e)xiii* 08-K-3g 0 Matrix m.3 s assistance programs.
* Note: For this element field,
5122-29-04(B)(1)(e) lists the
24 Asses- elements to be included when
PC.2.8 sment 2.B.9. clinically indicated, as determined
If Employed, Name of Employer (B)(1)(e)xiii* 08-K-3g 0 Matrix m.3 by the provider.
* Note: For this element field,
Job Performance History-check 5122-29-04(B)(1)(e) lists the
25
boxes for attendance, Asses- elements to be included when
performance, number of jobs in PC.2.8 sment 2.B.9. clinically indicated, as determined
past 5 years (B)(1)(e)xiii* 08-K-3g 0 Matrix m.3 by the provider.
* Note: For this element field,
5122-29-04(B)(1)(e) lists the
elements to be included when
clinically indicated, as determined
by the provider.
The client's mental illness may
have an impact on their
26 employability. Exploration of the
cognitive and other skills needed
for employment-not for a specific
job-should be explored here, e.g.
need to be able to follow
instructions, need to be able to pay
attention. Specific attention should
be given to those skills that have
Employment Interests/Skills: PC.2.8 been impacted by the mental
checklist and narrative (B)(1)(e)xiii* 08-K-3g 0 2.B.9 P illness.
8
Adult Diagnostic Assessment
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
3793:2-1-
5101:3-27 5122-29-04
08
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
* Note: For this element field,
5122-29-04(B)(1)(e) lists the
elements to be included when
27 clinically indicated, as determined
by the provider.
Military History-type, discharge PC.2.6 May be pertinent for a PTSD or
date, type of discharge (B)(1)(e)viii* 0 s another diagnosis.
* Note: For this element field,
PC.2.6 5122-29-04(B)(1)(e) lists the
0; elements to be included when
28 PC.2.7 clinically indicated, as determined
Outpatient Mental Health/AoD 0; Asses- by the provider.
Treatment-list agency, PC.3.1 sment 2.B.9. CARF is very prescriptive in this
current/past dates, clinician name (B)(1)(e)xxvi* 08-K-3k 10 Matrix g s area-see standard.
* Note: For this element field,
5122-29-04(B)(1)(e) lists the
elements to be included when
PC.2.6 clinically indicated, as determined
29 0; by the provider.
PC.2.7 May have some diagnostic
0; Asses- importance. May indicate need for
Psychiatric Hospitalizations-list PC.3.1 sment 2.B.9. more intensive programming if
hospital, dates, reason (B)(1)(e)xxvi* 08-K-3k 10 Matrix g s client is in a rapid cycle.
* Note: For this element field,
5122-29-04(B)(1)(e) lists the
elements to be included when
clinically indicated, as determined
30 PC.2.6 DTX3. by the provider.
0; 03;MH Current diagnosis only is important
PC.2.7 2.202; to Medicare and Medicaid for
0; PSR2. 2.B.9. medical necessity. Diagnoses that
Previous or current diagnoses: if PC.3.1 03;RP g; are no longer active should be
known (B)(1)(e)* 06-I 10 M7 2.B.9.i P clearly designated.
PC.2.6
0; * Note: For this element field,
PC.2.7 Asses- 5122-29-04(B)(1)(e) lists the
31
Other comments regarding Mental 0; sment elements to be included when
Health Treatment History- PC.3.1 Matrix; 2.B.9. clinically indicated, as determined
checkbox for "No Comments" (B)(1)(e)xxvi* 08-K-3k 10 RPM 7 g by the provider.
9
Adult Diagnostic Assessment
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
3793:2-1-
5101:3-27 5122-29-04
08
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
* Note: For this element field,
5122-29-04(B)(1)(e) lists the
PC.2.6 elements to be included when
0; clinically indicated, as determined
PC.2.7 by the provider.
32 0; Multiple co-morbidities may
PC.3.1 indicate a need for more intensive
10 2.B.9. interventions, closer oversight with
Current Medications: list Medical, PC.2.3 Asses- g; psychiatric medication
Psychiatric, OTC/Herbal-list 0; sment 2.B.9. management, and/or the need to
medication, rationale, total daily PC.2.4 Matrix; u; consult with other medical
dosage, compliance (B)(1)(e)xxvi* 08-K-3c 0 RPM7 2.B.9.v P providers.
Medicare requires that an attempt
be made with the client's
permission to contact the primary
care physician; CARF standard
33 requires name, address, and
telephone number somewhere in
the record- they do not specify that
Primary Care Physician: including this information has to be in the
name, address and phone 08-K-3e 2.G.3.f assessment.
34
Other Prescribing Physician(s) 08-K-3e
PC.2.3
0;
PC.2.4
0; 2.B.9. * Note: For this element field,
35
PC.2.5 g; 5122-29-04(B)(1)(e) lists the
Past Psychotropic Medications: list 0; 2.B.9. elements to be included when
medications and reasons for PC3.1 u; clinically indicated, as determined
discontinuation if appropriate (B)(1)(e)xxvi* 08-K-3c 10 RPM7 2.B.9.v by the provider.
Asses-
sment * Note: For this element field,
PC.3.6 Matrix; 5122-29-04(B)(1)(e) lists the
36 0;PC.3 MH2.0 elements to be included when
AOD Hx: yes/no & check boxes for .70;PC 3;PSR clinically indicated, as determined
abuse in past 12 mos. Of illegal, .3.80; 2.03R by the provider.
OTC, Prescribed Drugs and PC.3.1 TX3.0 2.B..9. CARF detox standards are listed in
Alcohol (B)(1)(e)ii* 08-K-3b,c 10 5 o P 3.J
10
Adult Diagnostic Assessment
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
3793:2-1-
5101:3-27 5122-29-04
08
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
PC.3.6
0;PC.3
.70;PC
37
.3.80;
AOD Hx:Toxicology Screen PC.3.1 2.B.9.
Completed and Results 10 o P
Asses-
sment
PC.3.6 Matrix;
38 0;PC.3 MH2.0
.70;PC 3;PSR
.3.80; 2.03R
AOD Hx: Presenting with Detox 05-F2;08- PC.3.1 TX3.0 2.B.9.
Issues-if yes, symptoms K-3q 10 5 o P
Asses-
sment
PC.3.6 Matrix;
39 0;PC.3 MH2.0
.70;PC 3;PSR
AOD Hx: check box-IV Drug User, .3.80; 2.03R
Pregnant, Other Addictive PC.3.1 TX3.0
Behaviors 08-K-3b 10 5 2.B.9
Asses-
sment
PC.3.6 Matrix;
40 0;PC.3 MH2.0 * Note: For this element field,
AOD Hx: Current/Past Usage .70;PC 3;PSR 5122-29-04(B)(1)(e) lists the
chart-list substance, age first used .3.80; 2.03R elements to be included when
and date of last use, frequency, PC.3.1 TX3.0 2.B.9. clinically indicated, as determined
amount, method (B)(1)(e)ii* 08-K-3b 10 5 o P by the provider.
Asses-
sment
PC.3.6 Matrix;
41 0;PC.3 MH2.0 * Note: For this element field,
.70;PC 3;PSR 5122-29-04(B)(1)(e) lists the
AOD Treatment Hx: check boxes- .3.80; 2.03R elements to be included when
levels of care and list agency and PC.3.1 TX3.0 2.B.9. clinically indicated, as determined
date of service (B)(1)(e)xxvi* 08-K-3d 10 5 g s by the provider.
11
Adult Diagnostic Assessment
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
3793:2-1-
5101:3-27 5122-29-04
08
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
AOD Hx: Other Comments
42 Regarding Substance Abuse/Use PC.3.6
including family/significant other 0;PC.3
AOD Hx, related legal problems, .70;PC
SAMI stage of treatment (for .3.80;
providers using Dual Disorders PC.3.1
Integrated Treatment Approach) 08-K-3b 10 2.B.9 P
* Note: For this element field,
5122-29-04(B)(1)(e) lists the
elements to be included when
clinically indicated, as determined
by the provider.
This information should be
gathered prior to the client's first
visit to ensure that the correct
individual is consenting to care,
acknowledging the agency's
privacy notice, authorizing release
43
of information, and participating in
treatment. Under HIPAA the
standards strongly encourage that
the determination of legal status
include a review of the appropriate
legal documentation not just the
verbal report of the individual
accompanying the client. CARF
requires name, address and phone
number. If a provider is seeking
Asses- CARF accreditation for Criminal or
Legal Hx: Legal sment Juvenile Justice programs the
Guardian/Custodian; Phone PC.2.1 Matrix; 2.G.3. applicable sections are 4C for
Number (B)(1)(e)xv* 08-K-3i 00 RPM7 b P adults and 4D2 for juveniles.
12
Adult Diagnostic Assessment
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
3793:2-1-
5101:3-27 5122-29-04
08
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
* Note: For this element field,
5122-29-04(B)(1)(e) lists the
elements to be included when
clinically indicated, as determined
by the provider.
For CARF completion of the legal
history sections do appear to meet
CARF's requirement for an
assessment of legal involvement.
See Section 4D Juvenile Justice if
obtaining accreditation in this
44 subcategory. Accreditors in
general want pertinent information.
Payers would be concerned re:
voluntary vs mandatory
participation if the client is court
involved or has been court ordered
into care, especially if the order is
for a higher level of care than is
needed as evidenced by the
Asses- documentation. JCAHO requires
sment that information be collected in this
Legal Hx: Client's current legal PC.2.1 Matrix; area that is relevant to the care,
status: checklist for AOD, MH and 00;PC. RPM 2.B.9. treatment, and services being
other legal involvement (B)(1)(e)xv* 08-K-3i 3.70 7.03 m s provided.
Asses- * Note: For this element field,
Legal Hx: History and Nature of sment 5122-29-04(B)(1)(e) lists the
45
legal charges (juvenile and adult), PC.2.1 Matrix; elements to be included when
including date of most recent 00;PC. RPM 2.B.9. clinically indicated, as determined
charges (B)(1)(e)xv* 08-K-3i 3.70 7.03 m by the provider.
Asses * Note: For this element field,
sment 5122-29-04(B)(1)(e) lists the
46
Matrix; elements to be included when
PC.2.1 RPM 2.B.9. clinically indicated, as determined
Legal Hx: Convictions (B)(1)(e)xv* 08-K-3i 00 7.03 m by the provider.
13
Adult Diagnostic Assessment
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
3793:2-1-
5101:3-27 5122-29-04
08
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
* Note: For this element field,
Legal Hx: Incarcerations and Asses- 5122-29-04(B)(1)(e) lists the
47 Name and Phone No. of sment elements to be included when
Probation/Parole Officer (if PC.2.1 Matrix; 2.B.9. clinically indicated, as determined
applicable) (B)(1)(e)xv* 08-K-3i 00 RPM7 m by the provider.
Asses- * Note: For this element field,
Legal Hx: Civil Proceedings and sment 5122-29-04(B)(1)(e) lists the
48
Domestic Relations Court Matrix; elements to be included when
Problems (i.e., Custody, Protective PC.2.1 RPM 2.B.9. clinically indicated, as determined
Services, Restraining Order) (B)(1)(e)xv* 08-K-3i 00 7.03 m by the provider.
* Note: For this element field,
5122-29-04(B)(1)(e) lists the
elements to be included when
clinically indicated, as determined
by the provider.
49 May speak indirectly to need if
adult or child was or is being
Asses- abused and that has resulted in a
sment diagnosable illness or has
Legal Hx: Juvenile Court Matrix; contributed to the severity of a
Involvement (Related to Child PC.2.1 RPM 2.B.9. current mental illness and is the
Abuse, Neglect, or Dependency) (B)(1)(e)xv* 08-K-3i 00 7.03 m s reason for seeking treatment.
Asses- * Note: For this element field,
sment 5122-29-04(B)(1)(e) lists the
50
Matrix; elements to be included when
Legal Hx: Child Enforcement PC.2.1 RPM 2.B.9. clinically indicated, as determined
Orders (B)(1)(e)xv* 00 7.03 m by the provider.
14
Adult Diagnostic Assessment
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
3793:2-1-
5101:3-27 5122-29-04
08
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
* Note: For this element field,
5122-29-04(B)(1)(e) lists the
elements to be included when
clinically indicated, as determined
by the provider.
May speak indirectly to need if
51 adult or child was or is being
abused and that has resulted in a
diagnosable illness or has
contributed to the severity of a
current mental illness and is the
Asses- reason for seeking treatment. May
sment indicate involuntary participation
Legal Hx: Children's Protective Matrix; on the part of an adult who is
Services Involvement with or PC.2.1 RPM seeking treatment solely to meet
checkbox "None Reported" (B)(1)(e)xii* 00 7.03 2.G.3 s requirements of another agency.
Legal Hx: Name of CPS
52 caseworkers assigned to family (if Necessary for case coordination-
applicable) or checkbox "None PC.2.1 2.B.9. may need to be on cover sheet for
Reported" 00 m ease of access as well.
Asses- * Note: For this element field,
sment 5122-29-04(B)(1)(e) lists the
53
Matrix; elements to be included when
Abuse History (Checklist with PC.3.1 RTX 2.B.9. clinically indicated, as determined
space for narrative description) (B)(1)(e)xxvii* 08-K-3l 0 3.03 m.6 s by the provider.
15
Adult Diagnostic Assessment
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
3793:2-1-
5101:3-27 5122-29-04
08
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
* Note: For this element field,
5122-29-04(B)(1)(e) lists the
elements to be included when
clinically indicated, as determined
by the provider.
The accreditors all require
sufficient information in the written
assessment to identify the
presenting problems, but do not
specifically list problems that must
be explored. For
Medicare/Medicaid: This list
provides evidence of functional
impairment and continuing
symptoms. Each of the domains
speak directly to the issue of
medical necessity. The list also
speaks indirectly to client benefit if
it is assumed that these are areas
where a BH intervention can
54
provide relief. You may want to
provide instructions to clinical staff
so that there is a standard
approach to the use of this form,
e.g. if a problem is listed as
moderate or high it must be
discussed in the clinical
formulation and a decision made
as to whether or not it is a high
priority for this treatment episode.
Then this should track directly to
the treatment plan. DMH requires
in standard B1(e)iii that the
behavioral/emotional/cognitive
functioning of the client be
addressed. ODADAS does not
Problem Checklist-Nutritional, require a problem checklist but
Eating Pattern Asses- does require that you list the
Changes/Disorders-As Evidenced PC.2.1 sment current problems of the client in 2-
By 06(F)(2)(c) (B)(1)(e)xvii* 10 Matrix P s 1-08(K)(3)(a).
16
Adult Diagnostic Assessment
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
3793:2-1-
5101:3-27 5122-29-04
08
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
This is a TJC requirement. If there
is a problem in this area, self
medication as a potential
55 substance abuse problem may
need to be explored with referral or
treatment discussed in the clinical
formulation and treatment
Problem Checklist-Pain PC.8.1 recommendations. This issue is
Management-As Evidenced By 0 P s also explored in the Health History.
Asses-
PC.2.7 sment
56
0; Matrix;
Problem Checklist-Depressed PC.2.1 DTX3.
Mood/Sad-As Evidenced By 08-K-3j 40 03 P s
PC.2.7
0; Asses-
57
Problem Checklist-Bereavement PC.2.1 sment
Issues-As Evidenced By 40 Matrix P s
PC.2.7
0; Asses-
58
Problem Checklist-Anxiety-As PC.2.1 sment
Evidenced By 08-K-3j 40 Matrix P s
Asses-
PC.2.7 sment
59
0; Matrix;
Problem Checklist-Traumatic PC.2.1 RTX
Stress-As Evidenced By 40 3.03 P s
PC.2.7
Problem Checklist- 0; Asses-
60
Anger/Aggression-As Evidenced PC.2.1 sment
By 08-K-3j 40 Matrix P s
PC.2.7
0; Asses-
61
Problem Checklist-Oppositional PC.2.1 sment
Behavior-As Evidenced By 40 Matrix P s
PC.2.7
0; Asses-
62
Problem Checklist-Inattention-As PC.2.1 sment
Evidenced By 40 Matrix P s
17
Adult Diagnostic Assessment
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
3793:2-1-
5101:3-27 5122-29-04
08
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
PC.2.7
0; Asses-
63
Problem Checklist-Impulsivity-As PC.2.1 sment
Evidenced By 40 Matrix P s
PC.2.7
Problem Checklist-Disturbed 0; Asses-
64
Reality Contact (psychosis)-As PC.2.1 sment
Evidenced By 08-K-3j 40 Matrix P s
PC.2.7
Problem Checklist-Mood 0; Asses-
65
Swings/Hyperactivity-As PC.2.1 sment
Evidenced By 40 Matrix P s
Asses-
sment * Note: For this element field,
66 PC.2.7 Matrix; 5122-29-04(B)(1)(e) lists the
0; MH2.0 elements to be included when
Problem Checklist-Substance PC.2.1 3;RTX 2.B.9. clinically indicated, as determined
Use/Addiction-As Evidenced By (B)(1)(e)ii* 08-K-3b 40 3.05 o P s by the provider.
PC.2.7
0;
67
Problem Checklist-Other Addictive PC.2.1
Behaviors-As Evidenced By 40 P s
PC.2.7
0;
68
Problem Checklist-Sleep PC.2.1
Problems-As Evidenced By 40 P s
PC.2.7
0; Asses-
69
Problem Checklist-Psychosocial PC.2.1 sment
Stressors-As Evidenced By 40 Matrix P s
Additional medical co-morbidities
provide evidence of increased
complexity of medical decision-
making or the need for time spent
70 on counseling and coordination of
Problem Checklist-Pertinent Asses- care, which may be important for
Health Issues (Including Allergies PC.2.3 sment Medicare billing if any agency is
and Food/Drug Reactions)-As 0;PC.2 Matrix; 2.B.9. using the Evaluation and
Evidenced By 08-K-3e,f .40 RPM 7 h P s Management codes.
18
Adult Diagnostic Assessment
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
3793:2-1-
5101:3-27 5122-29-04
08
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
PC.2.7
Problem Checklist-Family 0;
71
Education Needs-As Evidenced PC.2.1 2.B.8.
By 40 b P s
PC.2.7
Problem Checklist-Other 0;
72
Environmental Supports Needed- PC.2.1 2.B.9.
As Evidenced By 40 m P
May provide additional evidence
73 Problem Checklist-Other-As for the medical necessity of
Evidenced By P services.
* Note: For this element field,
Problem Checklist-Skills deficits, PC.2.7 5122-29-04(B)(1)(e) lists the
74 Training, Community Support 0; elements to be included when
Needs-Checkboxes-As Evidenced PC.2.1 clinically indicated, as determined
By (B)(1)(e)iii* 40 2.B.9 P P by the provider.
75 Ohio MH Consumer Outcomes 5122-28-
Administered-summarize results 04(A) s P
76 Other Outcomes Utilized- 5122-28-
summarize results 04(E)(2) s P
* Note: For this element field,
5122-29-04(B)(1)(e) lists the
elements to be included when
clinically indicated, as determined
by the provider.
The mental status exam provides
evidence of medical necessity by
77 looking at current symptomology,
evidence of client participation by
Asses- looking at the degree of
sment impairment the client has in
Matrix; communication and being
RTX communicated to, and the
3.03; potential benefit by identifying
PC.2.7 MH symptoms that can be addressed
Mental Status Examination (B)(1)(e)iv* 08-K-3j 0 2.02 2.B.9.k P P P by treatment.
19
Adult Diagnostic Assessment
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
3793:2-1-
5101:3-27 5122-29-04
08
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
* Note: For this element field,
5122-29-04(B)(1)(e) lists the
78 Asses- elements to be included when
Past Attempts to Harm Self or PC.2.1 sment 2.B.9. clinically indicated, as determined
Others-Checkboxes and Comment (B)(1)(e)xvi* 08-K-3k 0 Matrix b P by the provider.
* Note: For this element field,
5122-29-04(B)(1)(e) lists the
79 Asses- elements to be included when
Current Risk of Harm to Self- PC.2.1 sment 2.B.9. clinically indicated, as determined
Checkboxes and Comment (B)(1)(e)xvi* 08-K-3j 0 Matrix b P by the provider.
* Note: For this element field,
5122-29-04(B)(1)(e) lists the
80 Asses- elements to be included when
Current Risk of Harm to Others- PC.2.1 sment 2.B.9. clinically indicated, as determined
Checkboxes and Comment (B)(1)(e)xvi* 08-K-3j 0 Matrix b P by the provider.
Accreditors are not specific in their
requirements for documentation in
the assessment of
client/parent/guardian service
preferences. However, client's
81 willingness to discuss and list their
preferences does speak very
directly to their willingness to
participate in those services. For
PC.2.1 DTX4 CARF, addressing these areas
Client/Family/Guardian Expression 40 MH3 would assist in meeting the intent
of Service Preferences-Behavioral RI.2.3 PSR3 2.B.9. of Section 2.B.9, 2.B.10 and
Health, Clinical and Rehab 0 RTX4 d,f P s 2.B.11
See above. Payers and
accreditors both are looking for
PC.2.1 evidence that the client is willing
82
Client/Family/Guardian/Expression 40 and able to participate in their
of Service Preferences- RI.2.3 2.B.9. care. This documentation provides
Environmental Support 0 d,f P s support for this.
20
Adult Diagnostic Assessment
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
3793:2-1-
5101:3-27 5122-29-04
08
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
If the client is unable to adequately
communicate their history and
current status or problems, others
involved with the client can be
sources of this information. If the
client cannot be their own
historian, then a payer may
question the ability of the client to
participate in their care.
Documentation should clear this
up for the payer, e.g. "The client's
mom provided the information but
83 the client appeared attentive and
engaged and did participate in
some limited play. Client will be
assigned to a play therapist"; or,
"Client's house worker provided
much of the background
information because client has
difficulty expressing themselves in
English. Client does understand
English however and was attentive
during the session. Client will be
assigned to a Spanish speaking
therapist." Medicare allows for the
information to come from others,
without the client present.
This Clinical/Interpretative Medicaid allows for others to be
Summary is based on information 2.B.10 the source of information, but the
provided by-Checklist .b s s client must be present.
21
Adult Diagnostic Assessment
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
3793:2-1-
5101:3-27 5122-29-04
08
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
This is the primary place where an
auditor will go for a cogent
analysis and case for all of the
following: medical necessity, the
84 ability and willingness of the client
to participate and the ability of the
client to benefit. The clinical
formulation should defend the
Narrative Summary IM.6.2 2.B.10 diagnosis, level of care, and
(Clinical/Interpretative Summary) (B)(1)(c ) 0 .b P P P treatment recommendations.
All accreditors want the
information that is pertinent to
treatment so having additional
85
space for narrative that is
particular to the individual client is
Other Information important.
22
Adult Diagnostic Assessment
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
3793:2-1-
5101:3-27 5122-29-04
08
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
To meet the medical necessity
requirements of all payers there
must be one or more mental health
diagnoses which are the focus of
treatment. An auditor will look at
the diagnosis in combination with
the clinical summary, mental
status, and functional status
information to determine Medical
Necessity for the level of care and
services listed on ISP. Payers
differ as to whether they require
DSM or ICD codes for diagnosing.
In addition to mental health
86 diagnoses, accurately listing other
medical co-morbidities is important
as they may impact payer
decisions on how often and
intensely the client may need to be
seen. For example, a diabetic
client on certain psychotropics
which include development of a
type of diabetes or exacerbation of
existing diabetes as a side effect
may require additional
coordination of care, more
frequent medication management
sessions and additional and more
DTX3. frequent lab testing or other
03;PS diagnostics. Most accreditors
Diagnosis: narrative plus numeric R2.03; require a diagnosis and like payers
code and check box for primary IM.6.2 MH2.0 may require either DSM or ICD
Dx 06(F)(2)(b) (B)(1)(c ) 06-F6; 06-I 0 2 2.B.9.i P coding.
23
Adult Diagnostic Assessment
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
3793:2-1-
5101:3-27 5122-29-04
08
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
This is where the primary case for
client benefit is made by listing
prioritized needs (hopefully
resulting from a negotiation
between the clinician and client or
their representatives) and the level
87 of treatment that would be most
effective in meeting those needs.
This section also provides a
secondary case for participation if
client assisted in development of
list. And, finally, both participation
and ability to benefit are heavily
Treatment Asses- tied into the medical necessity of
Recommendations/Assessed sment services. Medicaid requires that
Needs; Check box for Deferred or IM.6.2 Matrix; this list be tied to the diagnosis as
Referred 02(A) (B)(1)(c ) 08-K-3r 0 RPM7 2.B.10 P s P well as the treatment plan.
Especially important if client is a
RPM7 child or is an adult with a legal
88 MH3 representative. Speaks directly to
Client/Guardian/Family DTX4 client's willingness to participate.
Participation in Assessment and IM.6.2 PSR3 COA- plan must be signed by
Response to Recommendations 0 CM4 2.B.8 P client/guardian.
24
Adult Diagnostic Assessment
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
3793:2-1-
5101:3-27 5122-29-04
08
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
* Note: For this element field,
5122-29-04(B)(1)(e) lists the
elements to be included when
clinically indicated, as determined
by the provider.
May be needed to rule out
additional diagnoses or to confirm
89
the current diagnosis. Medicaid
does require that additional
diagnostic work be done only if it
can provide unique and useful
information that cannot be
Asses- obtained at a lesser expense. Most
IM.6.2 sment payers want providers to follow the
Further Evaluations Needed 02(A) (B)(1)(e)* 08-K-3r 0 Matrix 2.B.10 s same guideline.
Payers require that services be
medically necessary and that care
be provided at the least restrictive
90 and least costly level of care that is
Level of Care (ODADAS requires safe for the client. Therefore, this
completion of Level of Care section needs to be congruent with
worksheet)/Indicated Services PC.2.7 the diagnosis and clinical
Recommended (A); (B)(1)(c ) 05-F 0 2.B.10 P formulation.
25
Adult Diagnostic Assessment
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
3793:2-1-
5101:3-27 5122-29-04
08
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
Signatures with credential of the
provider and date of the signature
are needed for billing. Auditor will
look to make sure that the
diagnosis and clinical formulation
has been completed by someone
with the training or credentials
required. Because the assessment
includes a determination of
diagnosis, the assessment must
have the signature of a person
91
with the credentials to diagnose.
This may be the signature of the
person completing the diagnosis,
may be the signature of an
individual who completes only the
diagnostic portion or oversees the
writing of this portion of the
assessment, or may be the
supervising professional who is
required to sign by some payers.
IM.6.1 Providers should be aware of
0; payer rules and should follow them
Provider 06-I-5;08- HR.5.1 RPM7. 2.B.7; regarding oversight and
Signature/Credential/Date 02(G)(4) (D)(1) K-4 0 04 2.G.2 signatures.
IM.6.1
Provider Signature rendering 0;
92
diagnosis if different than 06-I-5;08- HR.5.1 2.B.7; See above. May be needed for
above/Credential/Date 02(G)(4) K-4 0 2.G.2 billing.
IM.6.1
0;
93
Supervisor Signature (if HR.5.1 RPM7. 2.B.7; See above. May be needed for
applicable)/Credential/Date 02(G)(4) (D)(2) 08-K-4 0 04 2.G.2 billing.
IM.6.1
0;
94
Physician (D)(1)(a); HR.5.1 2.B.7; See above. May be needed for
Signature/Credential/Date 02(G)(4) (2)(a) 08-K-4 0 2.G.2 billing.
26
Adult Diagnostic Assessment
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
3793:2-1-
5101:3-27 5122-29-04
08
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
DMH/Medicaid: Initial diagnostic
must be completed prior to
services delivery except for crisis
intervention and emergency
95 medication management. Date of
service is required on the claim.
Medicaid references the DMH
06-N-2;08- requirements for this
Date of Service 02(G)(1) K-4 documentation.
96 Staff ID Number
97 Needed for billing; required by
Location Code Yes MACSIS
98 Needed for billing; required by
Procedure Code Yes MACSIS
99 Needed for billing; required by
Modifiers 1 to 4 Yes MACSIS
The code for the initial diagnostic
evaluation is not a time based
code in Medicare or for many other
payers. However, recording
100 accurate times can provide a
defense in the face of an audit and
does provide additional
compliance benefits in identifying
duplicate claims, confirmation that
Start Time 02(G)(2) 06-N-3 service was completed, etc.
101 Stop Time 02(G)(3) 06-N-3
Needed for billing; required by
102
Total Time 02(G)(3) 06-N-3 MACS
103 Needed for billing; required by
Diagnostic Code 06-I-2 P MACSIS
27
Compliance Grid for Ohio SOQIC Forms
Adult Diagnostic Assessment Update
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-04 3793:2-1-08
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
All payers require that the client be
identified. Also, National
Accreditors all require sufficient
identifying information. Best
1 practice requires that the name or
client number or both of the
individual appear at the top of
IM.6.2 every page in case the record
Client Name (First, MI, Last): Yes 06-F1 0 becomes disassembled.
Use of an ID number would allow
2 the PHI to be de-identified as
Client No. 06-F1 defined by HIPAA.
28
Adult Diagnostic Assessment Update
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-04 3793:2-1-08
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
Note: The accreditors do not
require that a separate diagnostic
update form be used to document
changes from the original
diagnostic, however, they do
require that there be a process of
continuing assessment and
documentation of continuing
assessment. Generally,
accreditors defer to practices of
provider and/or "as necessary."
3 Payers: DMH requires
assessments and updates at either
specified times, when changes
occur, or in response to treatment.
Medicaid has no requirement for
an update at specified times.
Medicare will only pay for an
update or new diagnostic every
three years or after a change in
level of care. ODADAS does not
require assessment updates at
specified times. It expects agency
policy to guide. The citations listed
below are those applicable to
Check-boxes for: Readmission; PC.2.1 diagnostic assessments in general
Update of New Information (A) 50 CM5 2.C.12 and not to updates alone.
Because this document is updating
4 information on a previous
assessment, the date of this
Date of Most Recent Assessment assessment must be listed.
5 Adult Diagnostic Assessment
Sections: checkboxes stating what RPM
will be updated and then narrative 7.02c
portion to explain further CM5 P P P
29
Adult Diagnostic Assessment Update
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-04 3793:2-1-08
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
To meet the medical necessity
requirements of all payers there
must be one or more mental health
diagnoses which are the focus of
treatment. An auditor will look at
the diagnosis in combination with
the clinical summary, mental
status exam, and functional status
information to determine Medical
Necessity for the level of care and
services listed on ISP. Payers
differ as to whether they require
DSM or ICD codes for diagnosing.
In addition to mental health
6
diagnoses, accurately listing other
medical co-morbidities is important
as they may impact payer
decisions on how often and
intensely the client may need to be
seen. For example, a diabetic
client on certain psychotropics
which include development of a
type of diabetes or exacerbation of
existing diabetes as side effect
may require additional
coordination of care, more
frequent medication management
DTX3. sessions and additional and more
03 frequent lab testing or other
PSR2. diagnostics. Most accreditors
Diagnosis-list full DSM or ICD-9 03 require a diagnosis and like payers
diagnosis code and narrative, or IM.6.2 MH2.0 may require either DSM or ICD
check box if No Change 06(F)(2)(b) (B)(1)(c ) 06-F6; 06-I 0 2 2.B.9.i coding.
Date of Most Recent
7 Administration of Ohio Mental
Health Consumer
Outcomes/Comments 5122-28-04
30
Adult Diagnostic Assessment Update
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-04 3793:2-1-08
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
Accreditors are not specific in their
requirements for documentation in
the assessment of
8 client/parent/guardian service
preferences. However, client's
Client/Family/Guardian PC.2.1 DTX4 willingness to discuss and list their
Expression of Service 40 MH3 preferences does speak very
Preferences: Behavioral Health 5122-27- RI.2.3 PSR3 2.B.9. directly to their willingness to
Clinical and Rehabilitative 05(A) 0 RTX4 d,f P s participate in those services.
See above. Payers and
accreditors both are looking for
Client/Family/Guardian PC.2.1 evidence that the client is willing
9
Expression of Service 40 and able to participate in their
Preferences: Environmental RI.2.3 2.B.9. care. This documentation provides
Supports 0 d,f P s support for this.
This is where the primary case for
client benefit is made by listing
prioritized needs (hopefully
resulting form a negotiation
between the clinician and client or
10 their representatives) and the level
of treatment that would be most
effective in meeting those needs.
This section also provides a
secondary case for participation if
Treatment Asses- client assisted in development of
Recommendations/Assessed sment list. Medicaid requires that this list
Needs; Check box for Deferred or IM.6.2 Matrix; be tied to the diagnosis as well as
Referred 02(A) (B)(1)(c ) 08-K-3r 0 RPM7 2.B.10 P s P the treatment plan.
31
Adult Diagnostic Assessment Update
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-04 3793:2-1-08
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
* Note: For this element field,
5122-29-04(B)(1)(e) lists the
elements to be included when
clinically indicated, as determined
by the provider.
May be needed to rule out
11 additional diagnoses or to confirm
the current diagnosis especially if
a new clinical picture is emerging.
Medicaid does require that
additional diagnostic work be done
only if it can provide unique and
useful information that cannot be
Asses- obtained at a lesser expense. Most
IM.6.2 sment payers want providers to follow the
Further Evaluations Needed 02(A) (B)(1)(e)* 08-K-3r 0 Matrix 2.B.10 s same guideline.
This is where the primary case for
client benefit is made by listing
prioritized needs (hopefully
resulting from a negotiation
between the clinician and client or
their representatives) and the level
12 of treatment that would be most
effective in meeting those needs.
This section also provides a
secondary case for participation if
client assisted in development of
list. And, finally, both participation
and ability to benefit are heavily
tied into the medical necessity of
services. Medicaid requires that
Level of Care/Indicated Services (A);(B)(1)(c PC.2.7 this list be tied to the diagnosis as
Recommended ) 05-F-6 0 2.B.10 P s P well as the treatment plan.
32
Adult Diagnostic Assessment Update
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-04 3793:2-1-08
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
Especially important if client is an
RPM7 adult with a legal representative.
MH3 Speaks directly to client's
13
DTX4 willingness to participate. COA-
Client/Guardian/Family Response PC.4.5 PSR3 plan must be signed by
to Recommendations 0; 60 CM4 2.B.8 P client/guardian.
The ISP should reflect the most
recent information on the client
14 including any changes to
For Updates-Change in ISP diagnostic or assessment
required checkbox information.
Needed for billing-Auditor will look
to make sure that diagnosis
changes and other information has
15 been completed by someone with
IM.6.1 the training to be able to do so.
0; The assessment must be signed
Provider 06-I-5; 08- HR.5.1 RPM 2.B.7; by a diagnosing professional, if the
Signature/Credential/Date 02(G)(4) (D)(1) K-4 0 7.04 2.G.2 diagnosis is changed or modified.
IM.6.1
0;
16
Supervisor Signature (if HR.5.1 RPM 2.B.7; See above. May be needed for
applicable)/Credential/Date 02(G)(4) (D)(2) 08-K-4 0 7.04 2.G.2 billing.
IM.6.1
Provider Signature rendering 0;
17
diagnosis if different than 06-I-5; 08- HR.5.1 2.B.7; See above. May be needed for
above/Credential/Date 02(G)(4) K-4 0 2.G.2 billing.
IM.6.1
0;
18
Physician Signature/Credential/(if (D)(1)(a); HR.5.1 2.B.7; See above. May be needed for
applicable)/Date 02(G)(4) (2)(a) 08-K-4 0 2.G.2 billing.
Date of service is required on the
claim. Medicaid references the
19
06-N-2;08- DMH requirements for this
Date of Service 02(G)(1) K-4 documentation.
20 Staff ID Number
21 Needed for billing; required by
Location Code Yes MACSIS
33
Adult Diagnostic Assessment Update
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-04 3793:2-1-08
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
Please see manual for cautions re:
what to consider before entering a
22
billing code for this service. Payer
rules must be understood and
Prcdr. Code Yes closely followed.
Depending on the code used for
billing this may or may not be a
23 time based service. However,
service times are important for
compliance reasons, e.g., to
Modifier (1-4) Yes identify duplicate claims.
24 Needed for billing; required by
Start Time 02(G)(2) 06-N-3 MACSIS
25 Stop Time 02(G)(3) 06-N-3
26 Needed for billing; required by
Total Time 02(G)(3) 06-N-3 MACSIS
27 Diagnosis-list full DSM or ICD-9 Needed for billing; required by
Diagnosis Code 06-I-2 P MACSIS
34
Compliance Grid for Ohio SOQIC Forms
Child/Adolescent Diagnostic Assessment
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-04 3793:2-1-08
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
All payers require that the client be
identified. Also, National
Accreditors all require sufficient
identifying information. Best
IM.6.2
1 Client Name (First, MI, Last): Yes 06-F-1 practice requires that the name or
0
client number or both of the
individual appear at the top of
every page in case the record
becomes disassembled.
Use of an ID number would allow
2 Client No.: 06-F-1 the PHI to be de-identified as
defined by HIPPA.
3 Date of Admission 2.G.3
Referral Source and Reason for RPM Needed for Medicare if billing
4 08-K-3a
Referral 7.02 consultation.
National accreditors don't list
CRI2.0
information needed specifically in
PC.2.1 3;DTX
presenting problem but want
0;PC.2 3.02;F
information gathered as
5 Client's Description of Problem (B)(1)(b) 08-K-3a .70; PS3.0 2.B.9 P
determined by the provider and as
IM.6.2 3;MH2
appropriate and necessary to
0 .01;PS
assist in assessment and
R2.02
treatment planning.
For children, parents may be only
Family/Guardian/Child/ PC.2.1
6 08-K-3a 2.B.9 P source of information on current
Perceptions of Problem 40
issues requiring treatment.
PC.2.7
* Note: For this element field,
0
Asses- 5122-29-04(B)(1)(e) lists the
PC.2.6
7 Living Situation: Checklist (B)(1)(e)v* sment elements to be included when
0
Matrix clinically indicated, as determined
PC.3.3
by the provider.
0
35
Child/Adolescent Diagnostic Assessment
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-04 3793:2-1-08
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
PC.2.7
Primary Household-HH members, * Note: For this element field,
(B)(1)(e)v*; 0
relationship to client, age, Asses- 5122-29-04(B)(1)(e) lists the
(B) PC.2.6
8 occupation/school, level of sment 2.B.9 elements to be included when
(1)(e)xxiv;( 0
education, quality of relationship, Matrix clinically indicated, as determined
B) (1)(e)(xii) PC.3.3
street address by the provider.
0
PC.2.7
* Note: For this element field,
(B)(1)(e)v*; 0
Asses- 5122-29-04(B)(1)(e) lists the
Secondary HH: Does client live in (B) PC.2.6
9 sment 2.B.9 elements to be included when
more than one household? (1)(e)xxiv;( 0
Matrix clinically indicated, as determined
B) (1)(e)(xii) PC.3.3
by the provider.
0
PC.2.7
Secondary HH: list HH members, * Note: For this element field,
(B)(1)(e)v*; 0
relationship to client, age, Asses- 5122-29-04(B)(1)(e) lists the
(B) PC.2.6
10 occupation/school, level of sment 2.B.9 elements to be included when
(1)(e)xxiv;( 0
education, quality of relationship, Matrix clinically indicated, as determined
B) (1)(e)(xii) PC.3.3
street address by the provider.
0
PC.2.7
* Note: For this element field,
(B)(1)(e)v*; 0
Asses- 5122-29-04(B)(1)(e) lists the
Family Members who live in both (B) PC.2.6
11 sment 2.B.9 elements to be included when
households (1)(e)xxiv;( 0
Matrix clinically indicated, as determined
B) (1)(e)(xii) PC.3.3
by the provider.
0
PC.2.7
* Note: For this element field,
(B)(1)(e)v*; 0
Additional Family Members, i.e. Asses- 5122-29-04(B)(1)(e) lists the
(B) PC.2.6
12 parents or siblings not living in sment 2.B.9 elements to be included when
(1)(e)xxiv;( 0
primary or secondary households Matrix clinically indicated, as determined
B) (1)(e)(xii) PC.3.3
by the provider.
0
* Note: For this element field,
5122-29-04(B)(1)(e) lists the
elements to be included when
clinically indicated, as determined
PC.2.7
Custody and Parenting Plan: Asses- 2.B.9; by the provider.
(B)(1)(e)v*; 0
Lives with both parents (biological sment 4.A.1. This information should be
(B) PC.2.6
13 or adoptive) in same household or Matrix; p; gathered prior to the client's first
(1)(e)xxiv;( 0
with widowed parent; Other, RPM 4.D.6. visit to ensure that the correct
B) (1)(e)(xii) PC.3.3
describe 7.03 p individual is consenting to care,
0
acknowledging the agency's
privacy notice, authorizing release
of information, and participating in
treatment. Under HIPAA the
36
Child/Adolescent Diagnostic Assessment
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-04 3793:2-1-08
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
standards strongly encourage that
the determination of legal status
include a review of the appropriate
legal documentation not just the
verbal report of the individual
accompanying the client.
Family
Environment/Relationships:
* Note: For this element field,
Parent-Child (Client)
Asses- 2.B.9; 5122-29-04(B)(1)(e) lists the
Relationship(s)-ratings: parent- PC.3.3
14 (B)(1)(e)xxi 08-K-3l sment 4.A.1; elements to be included when
child conflict, parent supervision, 0
v* Matrix 4.D.6 clinically indicated, as determined
cooperation between parents,
by the provider.
positive activities, satisfaction with
relationship (parent/child)
* Note: For this element field,
Asses- 2.B.9; 5122-29-04(B)(1)(e) lists the
Comment on Parent-Child (B)(1)(e)xxi PC.3.3
15 08-K-3l sment 4.A.1; elements to be included when
Relationships v* 0
Matrix 4.D.6 clinically indicated, as determined
by the provider.
* Note: For this element field,
Sibling-Child Relationship(s)-
Asses- 2.B.9; 5122-29-04(B)(1)(e) lists the
ratings: sibling-child conflict, (B)(1)(e)xxi PC.3.3
16 08-K-3l sment 4.A.1; elements to be included when
positive activities, satisfaction with v* 0
Matrix 4.D.6 clinically indicated, as determined
relationship (sibling/child)
by the provider.
* Note: For this element field,
Asses- 2.B.9; 5122-29-04(B)(1)(e) lists the
Comment on Sibling-Child (B)(1)(e)xxi PC.3.3
17 08-K-3l sment 4.A.1; elements to be included when
Relationships v* 0
Matrix 4.D.6 clinically indicated, as determined
by the provider.
* Note: For this element field,
Parent Marital or Couples Asses- 2.B.9; 5122-29-04(B)(1)(e) lists the
(B)(1)(e)xxi PC.3.3
18 Relationships-ratings: 08-K-3l sment 4.A.1; elements to be included when
v* 0
conflict/satisfaction Matrix 4.D.6 clinically indicated, as determined
by the provider.
* Note: For this element field,
Asses- 2.B.9; 5122-29-04(B)(1)(e) lists the
(B)(1)(e)xxi PC.3.3
19 Comment of Marital Relationship 08-K-3l sment 4.A.1; elements to be included when
v* 0
Matrix 4.D.6 clinically indicated, as determined
by the provider.
Other Family Concerns:
2.B.9;
alcohol/substance abuse, mental PC.3.3
20 08-K-3l 4.A.1;
health problems, health problems, 0
4.D.6
disability, legal issues, financial
37
Child/Adolescent Diagnostic Assessment
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-04 3793:2-1-08
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
2.B.9;
Comment on Other Family PC.3.3
21 08-K-3l 4.A.1;
Concerns 0
4.D.6
PC.2.7
* Note: For this element field,
0
Asses- 5122-29-04(B)(1)(e) lists the
(B)(1)(e)xxi PC.2.6
22 Pertinent Family History 08-K-3l sment 2.B.9 elements to be included when
v* 0
Matrix clinically indicated, as determined
PC.3.3
by the provider.
0
* Note: For this element field,
5122-29-04(B)(1)(e) lists the
elements to be included when
clinically indicated, as determined
by the provider.
Rehabilitation option services and
recovery programming should be
PC.2.7
built on the strengths and
0
Asses- capabilities of the client.
(B)(1)(e)xxii PC.2.6 2.B.9c,
23 Strengths/Capabilities 08-K-3o sment s s Interventions built on strengths can
i* 0 e
Matrix result in earlier successes and
PC.3.3
shorter and less expensive
0
interventions. COA as well as
other accreditors require strengths
assessments for special needs
populations. If strengths can be
used to build solutions and skills,
they should be considered in
treatment planning.
* Note: For this element field,
5122-29-04(B)(1)(e) lists the
elements to be included when
clinically indicated, as determined
by the provider.
PC.2.7
Any limitations should be
0
Asses- considered in determining the
Limitations of Activities of Daily (B)(1)(e)xxi* PC.2.6 2.B.9.
24 08-K-3p sment P Skills Deficits/Skills
Living ; xxii 0 d,l
Matrix Training/Community Support
PC.3.3
Needs on page 9 of the DA and
0
should be evaluated for inclusion
in the treatment plan. Services
directed toward reduction in these
limitations, if they are caused by or
result from the mental illness and
38
Child/Adolescent Diagnostic Assessment
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-04 3793:2-1-08
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
they interfere with the client's
ability to stay in the community or
move to a higher level of
functioning or recovery, make a
strong case for medical necessity.
* Note: For this element field,
5122-29-04(B)(1)(e) lists the
elements to be included when
clinically indicated, as determined
by the provider.
PC.2.7
COA and CARF are very
0
Asses- 2.B.9. interested in an assessment of
Friendship/Social Peer (B)(1)(e)xxi PC.2.6
25 sment m7;2. natural supports which includes
Support/Relationships v* 0
Matrix B.9.p friends, social and peer supports.
PC.3.3
These supports are expected to
0
substitute for some or all mental
health provider services over time.
The use of natural supports is a
key concept in recovery-based
service delivery systems.
* Note: For this element field,
5122-29-04(B)(1)(e) lists the
PC.2.7
elements to be included when
0
Asses- clinically indicated, as determined
PC.2.6
26 Meaningful Activities (B)(1)(e)vi* sment 2.B.9 s by the provider.
0
Matrix May indicate severe or moderate
PC.3.3
withdrawal as a diagnostic
0
indicator and/or a
rehabilitative/recovery focus.
* Note: For this element field,
5122-29-04(B)(1)(e) lists the
elements to be included when
clinically indicated, as determined
PC.2.7 by the provider.
0 Asses- For substance abusing clients, this
Community Supports/Self Help
PC.2.6 sment 2.B.9. may be their primary recovery
27 Groups (AA,NA, NAMI, Ohio (B)(1)(e)x* 08-K-3d s s
0 Matrix; m,p program. This information would
CFC,etc.)
PC.3.3 RPM 7 also be listed under AOD
0 treatment on page 7 of DA. For
MH clients peer supports may be a
significant component of their
recovery plan and a source of
social supports.
39
Child/Adolescent Diagnostic Assessment
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-04 3793:2-1-08
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
Asses- TJC specifically requires an
PC.3.1 sment 2.B.9. assessment of religion and
28 Religion/Spirituality (B)(1)(e)xxv 08-K-3n
00 Matrix; n spiritual orientation if the client is
RPM 7 substance abusing.
RPM7;
DMH specifically requires an
PC.2.7 CM3.0 2.B.9.
assessment of multicultural/ethnic
0 5;CRI2 n;
influences. The assessment
Cultural/Ethnic PC.2.6 .03;DT 4.A.1.c
29 (B)(1)a should include information on how
Issues/Information/Concerns 0 X3.04; ;
religion/spirituality impacts the
IM.6.2 MH2.0 4.D.6.
client's recovery from mental
0 3;PSR c
illness.
2.04
PC.2.7
0
* Note: For this element field,
Pertinent Developmental Issues PC.2.6 4.A.1.
Asses- 5122-29-04(B)(1)(e) lists the
(PDI)- Mother's Pregnancy History (B)(1)(e)i*;( 0 a;n
30 sment elements to be included when
(include prenatal exposure to B) (1)(e)vii IM.6.2 4.D.6.
Matrix clinically indicated, as determined
alcohol, tobacco or other drugs) 0 a
by the provider.
PC.3.3
0
PC.2.7
0
* Note: For this element field,
PC.2.6 4.A.1.
Asses- 5122-29-04(B)(1)(e) lists the
(B)(1)(e)i*;( 0 a;
31 PDI- Infancy (age 0-1) sment P elements to be included when
B) (1)(e)vii IM.6.2 4.D.6.
Matrix clinically indicated, as determined
0 a
by the provider.
PC.3.3
0
PC.2.7
0
* Note: For this element field,
PC.2.6 4.A.1.
Asses- 5122-29-04(B)(1)(e) lists the
(B)(1)(e)i*;( 0 a;
32 PDI- Preschool (age 2-4) sment P elements to be included when
B) (1)(e)vii IM.6.2 4.D.6.
Matrix clinically indicated, as determined
0 a
by the provider.
PC.3.3
0
PC.2.7
0 * Note: For this element field,
4.A.1.
PC.2.6 Asses- 5122-29-04(B)(1)(e) lists the
(B)(1)(e)i*;( a;
33 PDI- Childhood (age 5-12) 0 sment P elements to be included when
B) (1)(e)vii 4.D.6.
IM.6.2 Matrix clinically indicated, as determined
a
0 by the provider.
PC.3.3
40
Child/Adolescent Diagnostic Assessment
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-04 3793:2-1-08
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
0
PC.2.7
0
* Note: For this element field,
PC.2.6 4.A.1.
Asses- 5122-29-04(B)(1)(e) lists the
(B)(1)(e)i*;( 0 a;
34 PDI- Adolescent (age 13-17) sment P elements to be included when
B) (1)(e)vii IM.6.2 4.D.6.
Matrix clinically indicated, as determined
0 a
by the provider.
PC.3.3
0
* Note: For this element field,
5122-29-04(B)(1)(e) lists the
elements to be included when
clinically indicated, as determined
Asses- by the provider.
PDI- Sexual History to Include PC.2.6 2.B.9.
35 (B)(1)(e)xi* 08-K-3m sment The accreditors would like this
Pertinent Sexual Issues/Concerns 0 n
Matrix area explored because information
may be essential to recovery or
treatment. TJC states that if the
client has a history of sexual
abuse this information is required.
* Note: For this element field,
5122-29-04(B)(1)(e) lists the
PC.2.7 2.B.9.s elements to be included when
Asses-
0 ; clinically indicated, as determined
sment
School Functioning/Educational PC.2.6 4.A.1. by the provider. May
36 (B)(1)(e)xiv* 08-K-3h Matrix;
Classification 0 e; indicate learning difficulties that
DTX
IM.6.2 4.D.6. will have to be considered in
3.03
0 e developing community support
services, especially skill building in
both adults and children.
* Note: For this element field,
5122-29-04(B)(1)(e) lists the
elements to be included when
PC.2.7
clinically indicated, as determined
0
Checklist of Potential Disabilities, Asses- 2.B.9; by the provider. Medicaid
(B)(1)(e)xxi* PC.2.6
37 including: sensory, organic, sment 4.A.1; requires if it is MH related. This
; xxii 0
developmental, mental Matrix 4.D.6 information is especially critical if
IM.6.2
the provider intends to bill this
0
service under the interactive CPT
codes. If client has impairment that
impedes their ability to
41
Child/Adolescent Diagnostic Assessment
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-04 3793:2-1-08
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
communicate this must be noted. If
the client is unable to
communicate in any manner,
Medicare and Medicaid will likely
not pay for the service. Their ability
to communicate may also impact
their ability to benefit from
treatment. With Medicaid,
communication difficulties may
increase the length of time for a
service and therefore the charge
for the service. CARF standards
require this assessment to
determine if assisted technology or
resources are needed to aid in
assessment and treatment.
Asses-
sment
Comments on Educational
38 Matrix;
Classification/Placement
DTX
3.03
Asses- * Note: For this element field,
PC.6.1
sment 5122-29-04(B)(1)(e) lists the
0
39 School Functioning- Grades (B)(1)(e)xiv* Matrix; elements to be included when
PC.3.3
DTX clinically indicated, as determined
0
3.03 by the provider.
Asses- * Note: For this element field,
PC.6.1
sment 5122-29-04(B)(1)(e) lists the
Results From Above Exams (if 0
40 (B)(1)(e)xiv* Matrix; elements to be included when
taken) PC.3.3
DTX clinically indicated, as determined
0
3.03 by the provider.
Asses- * Note: For this element field,
PC.6.1
sment 5122-29-04(B)(1)(e) lists the
Other test results, i.e., IQ, 0
41 (B)(1)(e)xiv* Matrix; elements to be included when
achievement, etc. PC.3.3
DTX clinically indicated, as determined
0
3.03 by the provider.
Asses- * Note: For this element field,
PC.6.1
sment 5122-29-04(B)(1)(e) lists the
0
42 School Functioning- Attendance (B)(1)(e)xiv* Matrix; elements to be included when
PC.3.3
DTX clinically indicated, as determined
0
3.03 by the provider.
42
Child/Adolescent Diagnostic Assessment
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-04 3793:2-1-08
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
Asses- * Note: For this element field,
PC.6.1
sment 5122-29-04(B)(1)(e) lists the
School Functioning- Previous 0
43 (B)(1)(e)xiv* Matrix; elements to be included when
grade retentions PC.3.3
DTX clinically indicated, as determined
0
3.03 by the provider.
Asses- * Note: For this element field,
PC.6.1
sment 5122-29-04(B)(1)(e) lists the
School Functioning- 0
44 (B)(1)(e)xiv* Matrix; elements to be included when
Suspensions/expulsions PC.3.3
DTX clinically indicated, as determined
0
3.03 by the provider.
Asses- * Note: For this element field,
PC.6.1
sment 5122-29-04(B)(1)(e) lists the
School Functioning- Other 0
45 (B)(1)(e)xiv* Matrix; elements to be included when
Academic/School Concerns PC.3.3
DTX clinically indicated, as determined
0
3.03 by the provider.
* Note: For this element field,
Asses- 5122-29-04(B)(1)(e) lists the
PC.6.1 2.B.9.s
sment elements to be included when
School Functioning- Barriers to 0 ;
46 (B)(1)(e)xiv* Matrix; P P clinically indicated, as determined
Learning PC.3.3 4.A.1.i;
DTX by the provider. Medicaid
0 4.D.6.i
3.03 requires if it is MH related. See
also above under disabilities.
Asses- * Note: For this element field,
PC.6.1
sment 5122-29-04(B)(1)(e) lists the
School Functioning- Peer 0 4.A.1.l;
47 (B)(1)(e)xiv* Matrix; elements to be included when
Relationships/Social Functioning PC.3.3 4.D.6.l
DTX clinically indicated, as determined
0
3.03 by the provider.
* Note: For this element field,
5122-29-04(B)(1)(e) lists the
elements to be included when
clinically indicated, as determined
by the provider. This is
especially critical if the provider
Asses- 2.B.9.
intends to bill this service under
sment q;
(B)(1)(e)xxi* PC.2.7 the interactive CPT codes. If client
48 Special Communication Needs Matrix; 4.A.1.f P P P
; xxii 0 has impairment that impedes their
DTX ;
ability to communicate this must
3.03 4.D.6.f
be noted. If the client is unable to
communicate in any manner,
Medicare and Medicaid will likely
not pay for the service. Their ability
to communicate may also impact
their ability to benefit from
43
Child/Adolescent Diagnostic Assessment
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-04 3793:2-1-08
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
treatment. With Medicaid
communication difficulties may
increase the length of time for a
service and therefore the charge
for the service. CARF standards
require this assessment to
determine if assisted technology or
resources are needed to aid in
assessment and treatment.
* Note: For this element field,
5122-29-04(B)(1)(e) lists the
elements to be included when
clinically indicated, as determined
Asses- by the provider.
PC.2.1
sment 2.B.9. Accreditors want general, pertinent
Legal History-Current Legal 00
49 (B)(1)(e)xv* 08-K-3i Matrix; m; s information. May speak to
Status PC.3.7
RPM 4.D.5 voluntary vs mandatory
0
7.03 participation. TJC requires that
information is collected in this area
that is pertinent to the care,
treatment, and services being
planned or provided.
* Note: For this element field,
5122-29-04(B)(1)(e) lists the
elements to be included when
clinically indicated, as determined
by the provider.
For CARF completion of the legal
history sections do appear to meet
CARF's requirement for an
assessment of legal involvement.
Asses-
PC.2.1 Accreditors in general want
Legal History- History of Legal sment 2.B.9.
00 pertinent information. Payers
50 Charges/Name of Probation or (B)(1)(e)xv* 08-K-3i Matrix; m;
PC.3.7 would be concerned re: voluntary
Parole Officer (if applicable) RPM 4.D.5
0 vs mandatory participation if the
7.03
client is court involved or has been
court ordered into care, especially
if the order is for a higher level of
care than is needed as evidenced
by the documentation. TJC
requires that information be
collected in this area that is
relevant to the care, treatment and
services being provided.
44
Child/Adolescent Diagnostic Assessment
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-04 3793:2-1-08
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
Asses- * Note: For this element field,
PC.2.1
sment 2.B.9. 5122-29-04(B)(1)(e) lists the
00
51 Legal History- Adjudications (B)(1)(e)xv* 08-K-3i Matrix; m; elements to be included when
PC.3.7
RPM 4.D.5 clinically indicated, as determined
0
7.03 by the provider.
Asses- * Note: For this element field,
PC.2.1
sment 2.B.9. 5122-29-04(B)(1)(e) lists the
Legal History- Detentions or 00
52 (B)(1)(e)xv* 08-K-3i Matrix; m; elements to be included when
Incarcerations PC.3.7
RPM 4.D.5 clinically indicated, as determined
0
7.03 by the provider.
Asses- * Note: For this element field,
PC.2.1
sment 5122-29-04(B)(1)(e) lists the
00 2.B.9.
53 Legal History- Civil Proceedings (B)(1)(e)xv* 08-K-3i Matrix; elements to be included when
PC.3.7 m
RPM clinically indicated, as determined
0
7.03 by the provider.
* Note: For this element field,
5122-29-04(B)(1)(e) lists the
Asses-
PC.2.1 elements to be included when
sment
Legal History-Domestic Relations 00 2.B.9. clinically indicated, as determined
54 (B)(1)(e)xv* 08-K-3i Matrix;
Court Involvement PC.3.7 m by the provider.
RPM
0 May speak indirectly to need if
7.03
child abused and that is the reason
for seeking treatment.
* Note: For this element field,
5122-29-04(B)(1)(e) lists the
Asses-
PC.2.1 elements to be included when
Legal History- Juvenile Court sment 2.B.9.
00 clinically indicated, as determined
55 Involvement and Name of (B)(1)(e)xv* 08-K-3i Matrix; m; s
PC.3.7 by the provider.
Caseworker (if applicable) RPM 4.D.5
0 May speak indirectly to need if
7.03
child abused and that is the reason
for seeking treatment.
* Note: For this element field,
5122-29-04(B)(1)(e) lists the
Asses- elements to be included when
PC.2.1
Legal History- Children's sment clinically indicated, as determined
00 2.B.9.
56 Protective Services Involvement (B)(1)(e)xii* 08-K-3i Matrix; s by the provider.
PC.3.7 m
with Family RPM May speak indirectly to need if
0
7.03 child abused and that is the reason
for seeking treatment. May
indicate involuntary participation.
Legal History- Name of CPS PC.2.1 Asses- Necessary for case coordination-
2.B.9.
57 Caseworker(s) assigned to family 08-K-3i 00 sment may need to be on cover sheet for
m
(if applicable) PC.3.7 Matrix; ease of access as well.
45
Child/Adolescent Diagnostic Assessment
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-04 3793:2-1-08
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
0 RPM
7.03
* Note: For this element field,
5122-29-04(B)(1)(e) lists the
elements to be included when
clinically indicated, as determined
by the provider.
This information should be
gathered prior to the client's first
Asses- visit to ensure that the correct
PC.2.1
sment individual is consenting to care,
Legal History- Name of 00 2.B.9.
58 (B)(1)(e)xv* 08-K-3i Matrix; P acknowledging the agency's
GAL/CASA assigned to family PC.3.7 m
RPM privacy notice, authorizing release
0
7.03 of information, and participating in
treatment. Under HIPAA the
standards strongly encourage that
the determination of legal status
include a review of the appropriate
legal documentation not just the
verbal report of the individual
accompanying the client.
* Note: For this element field,
Asses- 5122-29-04(B)(1)(e) lists the
sment elements to be included when
Employment- Currently 2.B.9.
59 (B)(1)(e)xiii* 08-K-3g Matrix; s clinically indicated, as determined
Employed? m.3
DTX by the provider.
3.03 Accreditors request general
employment information.
Asses-
sment
2.B.9.
60 Employment-Name of Employer 08-K-3g Matrix;
m.3
DTX
3.03
Asses- * Note: For this element field,
sment 5122-29-04(B)(1)(e) lists the
2.B.9.
61 Employment- Job Title (B)(1)(e)xiii* 08-K-3g Matrix; elements to be included when
m.3
DTX clinically indicated, as determined
3.03 by the provider.
Asses- * Note: For this element field,
Employment- Employment PC.2.8 sment 2.B.9. 5122-29-04(B)(1)(e) lists the
62 (B)(1)(e)xiii* 08-K-3g P
Interests/Skills/Concerns 0 Matrix; m.3 elements to be included when
DTX clinically indicated, as determined
46
Child/Adolescent Diagnostic Assessment
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-04 3793:2-1-08
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
3.03 by the provider. Prevocational
skill building is reimbursable under
Medicaid. The client's mental
illness may have an impact on
their employability. Exploration of
the cognitive and other skills
needed for employment- not for a
specific job- should be explored
here, e.g. need to be able to follow
instructions, need to be able to pay
attention. Specific attention should
be given to those skills that have
been impacted by mental illness.
PC.2.6 4.A.1.
* Note: For this element field,
0 d;
Outpatient Mental Health Asses- 5122-29-04(B)(1)(e) lists the
(B)(1)(e)xxv PC.2.7 4.D.6.
63 Treatment: Agency, Current or 08-K-3k sment s elements to be included when
i* 0 d;
Past Tx, Clinician Matrix clinically indicated, as determined
PC.3.1 2.B.9.
by the provider.
10 g
* Note: For this element field,
5122-29-04(B)(1)(e) lists the
PC.2.6 4.A.1.
elements to be included when
Psychiatric 0 d;
Asses- clinically indicated, as determined
Hospitalizations/Residential PC.2.7 4.D.6.
64 (B)(1)(e)xiii* 08-K-3k sment s by the provider.
Treatment: Facility, Dates of 0 d;
Matrix May have some diagnostic
Service, Reason PC.3.1 2.B.9.
importance. May indicate need for
10 g
more intensive programming if
client is in rapid cycle.
* Note: For this element field,
5122-29-04(B)(1)(e) lists the
PC.2.6 DTX3. elements to be included when
0 03;MH clinically indicated, as determined
Previous or Current Diagnosis (if (B)(1)(e)xixi PC.2.7 2.202; 2.B.9. by the provider.
65 06-I P
known) * 0 PSR2. g.,i Current diagnosis only is important
PC.3.1 03;RP to Medicare and Medicaid for
10 M7 medical necessity. Diagnoses that
are no longer active should be
clearly designated.
PC.2.6
0 Asses-
Other Comments- Mental Health PC.2.7 sment 2.B.9.
66 08-K-3k
History Treatment 0 Matrix; g
PC.3.1 RPM 7
10
47
Child/Adolescent Diagnostic Assessment
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-04 3793:2-1-08
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
* Note: For this element field,
PC.2.6 5122-29-04(B)(1)(e) lists the
0 elements to be included when
PC.2.7 clinically indicated, as determined
Current Medications: 2.B.9.
0 Asses- by the provider.
Prescription/OTC/Herbal- list g;
(B)(1)(e)xxv PC.3.1 sment Multiple co-morbidities may
67 medication, rationale, dosage, 08-K-3c 2.B.9. P
i* 10 Matrix; indicate a need for more intensive
route, frequency, checklist for u;
PC.2.3 RPM 7 interventions, closer oversight with
compliance 2.B.9.v
0 psychiatric medication
PC.2.4 management, and/or the need to
0 consult with other medical
providers.
Medicare requires that an attempt
Primary Care Physician: Name, be made with the client's
68 08-K-3e 2.G.3.f
Address, Phone permission to contact the primary
care physician.
69 Other Prescribing Physicians 08-K-3e
PC.3.1 2.B.9. * Note: For this element field,
Asses-
10 g; 5122-29-04(B)(1)(e) lists the
Past Pyshcotropic Medications (B)(1)(e)xixi sment
70 08-K-3c PC.2.3 2.B.9. elements to be included when
and Reason for Discontinuation * Matrix;
0, 40, u; clinically indicated, as determined
RPM 7
50 2.B.9.v by the provider.
Asses- 2.B.9.
* Note: For this element field,
AOD Hx: yes/no check boxes for PC.3.6 sment o;
5122-29-04(B)(1)(e) lists the
abuse in past 12 mos. Of illegal, 0, 70, Matrix; 4.A.1.
71 (B)(1)(e)ii* 08-K-3b,c P elements to be included when
OTC, prescribed drugs and 80, MH2.0 o;
clinically indicated, as determined
alcohol 110 3;RTX 4.D.6.
by the provider.
3.05 o
2.B.9.
PC.3.6 o;
AOD Hx: Toxicology Screen 0, 70, 4.A.1.
72 P
Completed and Results 80, o;
110 4.D.6.
o
Asses- 2.B.9.
AOD Hx: Presenting with Detox
PC.3.6 sment o;
Issues: list symptoms, and check
05-F2;08-K- 0, 70, Matrix; 4.A.1.
73 all that apply: IV Drug User, P
3q 80, MH2.0 o;
Pregnant and Other Addictive
110 3;RTX 4.D.6.
Behaviors
3.05 o
48
Child/Adolescent Diagnostic Assessment
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-04 3793:2-1-08
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
Asses- 2.B.9.
PC.3.6 sment o;
AOD History: List substances
0, 70, Matrix; 4.A.1.
74 used, age of first use, frequency, 08-K-3b P
80, MH2.0 o;
amount and method
110 3;RTX 4.D.6.
3.05 o
Asses- 4.A.1.
* Note: For this element field,
AOD Treatment History: list PC.3.6 sment d;
5122-29-04(B)(1)(e) lists the
agencies and dates of service, (B)(1)(e)xxv 0, 70, Matrix; 4.D.6.
75 08-K-3d s elements to be included when
type of service, current or past ii* 80, MH2.0 d;
clinically indicated, as determined
level of care 110 3;RTX 2.B.9.
by the provider.
3.05 g
AOD Hx: Other Comments
Regarding Substance
Abuse/Use/Other Addictive
Behaviors- include AOD PC.3.6
2.B.9;
use/abuse by family 0, 70,
76 08-K-3b 4.A.1; P
members/significant others, AoD 80, 90,
4.D.6
related legal problems, SAMI 110
stage of treatment for providers
using Dual Disorders Integrated
Treatment Approach
* Note: For this element field,
5122-29-04(B)(1)(e) lists the
elements to be included when
clinically indicated, as determined
Abuse History (Checklist of Asses-
by the provider.
physical and/or emotional abuse sment
(B)(1)(e)xxv PC.3.1 2.B.9. May speak indirectly to need if
77 and/or sexual, community 08-K-3l Matrix; s
ii* 00 m adult or child was or is being
violence with space for narrative RTX
abused and that has resulted in a
description) 3.03
diagnosable illness or has
contributed to the severity of a
current mental illness and is the
reason for seeking treatment.
The accreditors all require
sufficient information in the written
assessment to identify the
Problem Checklist- Nutritional presenting problems, but do not
Asses-
Eating Pattern PC.2.1 specifically list problems that must
78 06(F)(2)(c ) sment P s s
Changes/Disorders- As Evidenced 10 be explored. For
Matrix
By Medicare/Medicaid: This list
provides evidence of functional
impairment and continuing
symptoms. Each of the domains
49
Child/Adolescent Diagnostic Assessment
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-04 3793:2-1-08
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
speak directly to the issue of
medical necessity. The list also
speaks indirectly to client benefit if
it is assumed that these are areas
where a BH intervention can
provide relief. You may want to
provide instructions to clinical staff
so that there is a standard
approach to the use of this form,
e.g. if a problem is listed as
moderate or high it must be
discussed in the clinical
formulation and a decision made
as to whether or not it is a high
priority for this treatment episode.
Then this should track directly to
the treatment plan. DMH requires
in standard B(1)(e)iii that the
behavioral/emotional/cognitive
functioning of the client be
addressed. ODADAS does not
require a problem checklist but
does require that you list the
current presenting problem of the
client--2-1-08(K)(3)(a).
This is a TJC requirement. If there
is a problem in this area, self
medication as a potential
substance abuse problem may
Problem Checklist- Pain PC.8.1
79 P s need to be explored with referral or
Management- As Evidenced By 0
treatment discussed in the clinical
formulation and treatment
recommendations. This issue is
also explored in the Health History.
PC.2.7
Asses-
Problem Checklist- Depressed 0
80 08-K-3j sment P s
Mood/Sad- As Evidenced By PC.2.1
Matrix
40
PC.2.7
Asses-
Problem Checklist- Bereavement 0
81 sment P s
Issues- As Evidenced By PC.2.1
Matrix
40
50
Child/Adolescent Diagnostic Assessment
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-04 3793:2-1-08
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
PC.2.7
Asses-
Problem Checklist- Anxiety- As 0
82 08-K-3j sment P s
Evidenced By PC.2.1
Matrix
40
Asses-
PC.2.7
sment
Problem Checklist- Traumatic 0
83 Matrix; P s
Stress- As Evidenced By PC.2.1
RTX
40
3.03
PC.2.7
Problem Checklist- Asses-
0
84 Anger/Aggression- As Evidenced 08-K-3j sment P s
PC.2.1
By Matrix
40
PC.2.7
Asses-
Problem Checklist- Oppositional 0
85 sment P s
Behavior- As Evidenced By PC.2.1
Matrix
40
PC.2.7
Asses-
Problem Checklist- Inattention- As 0
86 sment P s
Evidenced By PC.2.1
Matrix
40
PC.2.7
Asses-
Problem Checklist- Impulsivity- As 0
87 sment P s
Evidenced By PC.2.1
Matrix
40
PC.2.7
Problem Checklist- Disturbed Asses-
0
88 Reality Contact (psychosis)- As 08-K-3j sment P s
PC.2.1
Evidenced By Matrix
40
PC.2.7
Problem Checklist- Mood Asses-
0
89 Swings/Hyperactivity- As sment P s
PC.2.1
Evidenced By Matrix
40
Asses- 2.B.9.
* Note: For this element field,
PC.2.7 sment o;
5122-29-04(B)(1)(e) lists the
Problem Checklist- Substance 0 Matrix; 4.A.1.
90 (B)(1)(e)ii* 08-K-3b P s elements to be included when
Use/Addiction- As Evidenced By PC.2.1 MH2.0 o;
clinically indicated, as determined
40 3;RTX 4.D.6.
by the provider.
3.05 o
PC.2.7
Problem Checklist- Other
0
91 Addictive Behaviors- As P s
PC.2.1
Evidenced By
40
51
Child/Adolescent Diagnostic Assessment
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-04 3793:2-1-08
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
PC.2.7
Problem Checklist- Sleep 0
92 P s
Problems- As Evidenced By PC.2.1
40
PC.2.7
Problem Checklist-
0
93 Enuresis/Encopresis- As P s
PC.2.1
Evidenced By
40
PC.2.7
Asses-
Problem Checklist- Psychosocial 0
94 sment P s
Stressors- As Evidenced By PC.2.1
Matrix
40
Additional medical co-morbidities
2.B.9.
provide evidence of increased
Problem Checklist- Pertinent PC.2.7 Asses- h;
complexity of medical decision-
Health Issues (Include Any 0 sment 4.A.1.
95 08-K-3e,f P s making which may be important for
Allergies and Food/Drug PC.2.1 Matrix; b;
Medicare billing if an agency is
Reactions)- As Evidenced By 40 RPM 7 4.D.6.
using the Evaluation and
b
Management codes.
* Note: For this element field,
(B)(1)(e)iii*, PC.2.7
Problem Checklist- Family 5122-29-04(B)(1)(e) lists the
(B) 0 2.B.8.
96 Education Needed- As Evidenced P s elements to be included when
(1)(e)xxi,xxii PC.2.1 b
By clinically indicated, as determined
, xxiii 40
by the provider.
* Note: For this element field,
(B)(1)(e)iii*, PC.2.7
Problem Checklist- Other 5122-29-04(B)(1)(e) lists the
(B) 0 2.B.9.
97 Environmental Supports Needed- P elements to be included when
(1)(e)xxi,xxii PC.2.1 m
As Evidenced By clinically indicated, as determined
, xxiii 40
by the provider.
May provide additional evidence
Problem Checklist- Other- As
98 P for the medical necessity of
Evidenced By
services.
* Note: For this element field,
Problem Checklist- Skills Deficits, (B)(1)(e)iii*, PC.2.7
5122-29-04(B)(1)(e) lists the
Skills Training, Community (B) 0
99 2.B.9 P P elements to be included when
Support Needs- Checkboxes- As (1)(e)xxi,xxii PC.2.1
clinically indicated, as determined
Evidenced By , xxiii 40
by the provider.
Ohio Mental Health Consumer
100 Outcomes Administered- 5122-28-04 s P
summarize results
52
Child/Adolescent Diagnostic Assessment
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-04 3793:2-1-08
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
Other Outcome Tools Utilized-
101
summarize results
Asses-
sment * Note: For this element field,
Mental Status Summary: checklist Matrix; 5122-29-04(B)(1)(e) lists the
102 for remarkable or not; or not (B)(1)(e)iv* RTX 2.B.9.k P P P elements to be included when
clinically indicated 3.03; clinically indicated, as determined
MH by the provider.
2.02
* Note: For this element field,
5122-29-04(B)(1)(e) lists the
elements to be included when
clinically indicated, as determined
by the provider.
Asses-
The mental status exam provides
sment
evidence of medical necessity by
Matrix;
PC.2.7 looking at current symptomology,
103 Mental Status Examination (B)(1)(e)iv* 08-K-3j RTX 2.B.9.k P P P
0 evidence of client participation by
3.03;
looking at the degree of
MH
impairment the client has in
2.02
communicating and being
communicated to, and the
potential benefit by identifying
symptoms that can be addressed
by treatment.
Asses- * Note: For this element field,
Past Attempts to Harm Self or sment 5122-29-04(B)(1)(e) lists the
PC.2.1 2.B.9.
104 Others- Checkboxes and (B)(1)(e)xvi* 08-K-3j Matrix; P elements to be included when
0 b
Comment CRI clinically indicated, as determined
2.03 by the provider.
Asses- * Note: For this element field,
sment 5122-29-04(B)(1)(e) lists the
Current Risk of Harm to Self- PC.2.1 2.B.9.
105 (B)(1)(e)xvi* 08-K-3j Matrix; P elements to be included when
Checkboxes and Comment 0 b
CRI clinically indicated, as determined
2.03 by the provider.
Asses- * Note: For this element field,
sment 5122-29-04(B)(1)(e) lists the
Current Risk of Harm to Others- PC.2.1 2.B.9.
106 (B)(1)(e)xvi* 08-K-3j Matrix; P elements to be included when
Checkboxes and Comment 0 b
CRI clinically indicated, as determined
2.03 by the provider.
53
Child/Adolescent Diagnostic Assessment
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-04 3793:2-1-08
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
Accreditors are not specific in their
requirements for documentation in
the assessment of
client/parent/guardian service
preferences. However, client's
Client/Family/Guardian PC.2.1
5122-27- DTX4 willingness to discuss and list their
Expression of Service 40 2.B.9.
107 05(A),(A)(3) MH3 P s preferences does speak very
Preferences- Behavioral RI.2.3 d,f
, (A)(4) RTX4 directly to their willingness to
Health/Clinical and Rehabilitative 0
participate in those services. For
CARF, addressing these areas
would assist in meeting the intent
of Section 2.B.9, 2.B.10 and
2.B.11
See above. Payers and
Client/Family/Guardian PC.2.1 accreditors both are looking for
Expression of Service 5122-27- 40 2.B.9. evidence that the client is willing
108 P s
Preferences- Environmental 05(A),(A)(3) RI.2.3 d,f and able to participate in their
Support 0 care. This documentation provides
support for this.
If the client is unable to adequately
communicate their history and
current status or problems, others
involved with the client can be
sources of this information. If the
client cannot be their own
historian, than a payer may
question the ability of the client to
participate in their care.
Documentation should clear this
up for the payer, e.g. "The client's
mom provided the information but
This clinical summary is based on 2.B.10
109 s s the client appeared attentive and
information provided… (checklist) .b
engaged and did participate in
some limited play. Client will be
assigned to a play therapist" or
"Client's house worker provided
much of the background
information because client has
difficulty expressing themselves in
English. Client does understand
English, however and was
attentive during the session. Client
will be assigned to a Spanish
speaking therapist." Medicare
54
Child/Adolescent Diagnostic Assessment
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-04 3793:2-1-08
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
allows for the information to come
from others, without the client
present. Medicaid allows for others
to be the source of information, but
the client must be present.
This is the primary place where an
auditor will go for a cogent
analysis and case for all of the
following: medical necessity, the
IM.6.2 2.B.10 ability and willingness of the client
110 Clinical Summary- Narrative (B)(1)(c ) P P P
0 .b to participate and the ability of the
client to benefit. The clinical
formulation should defend the
diagnosis, level of care and
treatment recommendations.
All accreditors want the
information that is pertinent to
treatment so having additional
111 Other Information
space for narrative that is
particular to the individual client is
important.
To meet the medical necessity
requirements of all payers there
must be one or more mental health
diagnoses which are the focus of
treatment. An auditor will look at
the diagnosis in combination with
the clinical summary, mental
status, and functional status
information to determine Medical
DTX3. Necessity for the level of care and
03;PS services listed on ISP. Payers
IM.6.2
112 Diagnosis 06(F)(b) (B)(1)(c ) 06-F6; 06-I R2.03; 2.B.9.i P differ as to whether they require
0
MH2.0 DSM or ICD codes for diagnosing.
2 In addition to mental health
diagnoses, accurately listing other
medical co-morbidities is important
as they may impact payer
decisions on how often and
intensely the client may need to be
seen. For example, a diabetic
client on certain psychotropics
which include development of a
type of diabetes or exacerbation of
55
Child/Adolescent Diagnostic Assessment
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-04 3793:2-1-08
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
existing diabetes as a side effect
may require additional
coordination of care, more
frequent medication management
sessions and additional and more
frequent lab testing or other
diagnostics. Most accreditors
require a diagnosis and like payers
may require either DSM or ICD
coding.
This is where the primary case for
client benefit is made by listing
prioritized needs (hopefully
resulting from a negotiation
between the clinician and client or
their representatives) and the level
of treatment that would be most
Treatment Asses-
effective in meeting those needs.
Recommendations/Assessed IM.6.2 sment
113 02(A) (B)(1)(c ) 08-K-3r 2.B.10 P s P This section also provides a
Needs; Check box for Deferred or 0 Matrix;
secondary case for participation if
Referred RPM 7
client assisted in development of
list. And, finally, both participation
and ability to benefit are heavily
tied into the medical necessity of
services. Medicaid requires that
this list be tied to the diagnosis as
well as the treatment plan.
2.B.8. Especially important if client is a
RPM7 b; child or is an adult with a legal
Client/Guardian/Family
5122-27- IM.6.2 MH3 4.A.1. representative. Speaks directly to
114 Participation in Assessment and P
05(A),(A)(4) 0 DTX4 q; client's willingness to participate.
Response to Recommendations
CM4 4.D.6. COA- plan must be signed by
q client/guardian.
May be needed to rule out
additional diagnoses or to confirm
the current diagnosis. Medicaid
does require that additional
Asses-
IM.6.2 diagnostic work be done only if it
115 Further Evaluations Needed 02(A) 08-K-3r sment 2.B.10 s
0 can provide unique and useful
Matrix
information that cannot be
obtained at a lesser expense. Most
payers want providers to follow the
same guideline.
56
Child/Adolescent Diagnostic Assessment
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-04 3793:2-1-08
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
Payers require that services be
medically necessary and that care
Level of Care (ODADAS requires be provided at the least restrictive
completion of Level of Care PC.2.7 and least costly level of care that is
116 (A) 05-F 2.B.10 P
worksheet)/Indicated Services 0 safe for the client. Therefore, this
Recommended section needs to be congruent with
the diagnosis and clinical
formulation.
Signatures with credential of the
provider and date of the signature
are needed for billing. Auditor will
look to make sure that the
diagnosis and clinical formulation
has been completed by someone
with the training or credentials
required. Because the assessment
includes a determination of
diagnosis, the assessment must
have the signature of a person
IM.6.1
with the credentials to diagnose.
Provider 06-I-5; 08- 0 RPM 2.B.7;
117 02(G)(4) (C )(1) This may be the signature of the
Signature/Credential/Date K-4 HR.5.1 7.04 2.G.2
person completing the diagnosis,
0
may be the signature of an
individual who completes only the
diagnostic portion or oversees the
writing of this portion of the
assessment, or may be the
supervising professional who is
required to sign by some payers.
Providers should be aware of
payer rules and should follow them
regarding oversight and
signatures.
IM.6.1
Provider Signature rendering
06-I-5; 08- 0 2.B.7; See above. May be needed for
118 diagnosis if different than 02(G)(4) (C )(1)
K-4 HR.5.1 2.G.2 billing.
above/Credential/Date
0
IM.6.1
Supervisor Signature (if 0 RPM 2.B.7; See above. May be needed for
119 02(G)(4) (C )(2) 08-K-4
applicable)/Credential/Date HR.5.1 7.04 2.G.2 billing.
0
57
Child/Adolescent Diagnostic Assessment
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-04 3793:2-1-08
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
IM.6.1
Physician Signature/ 0 2.B.7; See above. May be needed for
120 02(G)(4) (C )(1)(a) 08-K-4
Credential/Date HR.5.1 2.G.2 billing.
0
DMH/Medicaid: Initial diagnostic
must be completed prior to
services delivery except for crisis
intervention and emergency
06-N-2; 08-
121 Date of Service 02(G)(1) medication management. Date of
K-4
service is required on the claim.
Medicaid references the DMH
requirements for this
documentation.
122 Staff ID Number
Needed for billing; required by
123 Location Code Yes
MACSIS
Needed for billing; required by
124 Procedure Code Yes
MACSIS
Needed for billing; required by
125 Modifiers 1 to 4 Yes
MACSIS
The code for the initial diagnostic
evaluation is not a time based
code in Medicare or for many other
payers. However, recording
accurate times can provide a
126 Start Time 02(G)(2) 06-N-3
defense in the face of an audit and
does provide additional
compliance benefits in identifying
duplicate claims, confirmation that
service was completed, etc.
Needed for billing; required by
127 Stop Time 02(G)(3) 06-N-3
MACSIS
58
Child/Adolescent Diagnostic Assessment
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-04 3793:2-1-08
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
Needed for billing; required by
128 Total Time 02(G)(3) 06-N-3
MACSIS
Needed for billing; required by
129 Diagnostic Code 06-I-2
MACSIS
59
Compliance Grid for Ohio SOQIC Forms
Child/Adolescent Diagnostic Assessment Update
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
3793:2-1-
5101:3-27 5122-29-04
08
No.
Medical Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Client Benefit Comments
Necessity Participation
Form
All payers require that the client be
identified. Also, National
Accreditors all require sufficient
identifying information. Best
1 practice requires that the name or
client number or both of the
individual appear at the top of
every page in case the record
Client Name (First, MI, Last): Yes 06-F1 IM.6.20 becomes disassembled.
Use of an ID number would allow
2 the PHI to be de-identified as
Client No. 06-F1 defined by HIPAA.
60
Child/Adolescent Diagnostic Assessment Update
Note: The accreditors do not
require that a separate diagnostic
update form be used to document
changes from the original
diagnostic, however, they do
require that there be a process of
continuing assessment and
documentation of continuing
assessment. Generally,
accreditors defer to practices of
provider and/or "as necessary."
3 Payers: DMH requires
assessments and updates at either
specified times, when changes
occur, or in response to treatment.
Medicaid has no requirement for
an update at specified times.
Medicare will only pay for an
update or new diagnostic every
three years or after a change in
level of care. ODADAS does not
require assessment updates at
specified times. It expects agency
policy to guide. The citations listed
Check-boxes for: below are those applicable to
Readmission; Update of New diagnostic assessments in general
Information (A) PC.2.150 CM5 2.C.12 and not to updates alone.
Because this document is updating
4 information on a previous
Date of Most Recent assessment, the date of this
Assessment assessment must be listed.
Child Diagnostic Assessment
Sections: checkboxes stating
5
what will be updated and RPM
then narrative portion to 7.02c
explain further CM5 P P P
61
Child/Adolescent Diagnostic Assessment Update
To meet the medical necessity
requirements of all payers there
must be one or more mental health
diagnoses which are the focus of
treatment. An auditor will look at
the diagnosis in combination with
the clinical summary, mental
status exam, and functional status
information to determine Medical
Necessity for the level of care and
services listed on ISP. Payers
differ as to whether they require
DSM or ICD codes for diagnosing.
In addition to mental health
6 diagnoses, accurately listing other
medical co-morbidities is important
as they may impact payer
decisions on haw often and
intensely the client may need to be
seen. For example, a diabetic
client on certain psychotropics
which include development of a
type of diabetes or exacerbation of
existing diabetes as side effect
may require additional
coordination of care, more
frequent medication management
sessions and additional and more
frequent lab testing or to her
Diagnosis-list full DSM or diagnostics. Most accreditors
ICD-9 diagnosis code and require a diagnosis and like payers
narrative, or check box if No DTX3.03 may require either DSM or ICD
Change (B)(1)(c ) 06-F6; 06-I IM.6.20 MH2.02 2.B.9.i P coding.
Date of Most Recent
Administration of Ohio
7 Mental Health Consumer
Outcomes/Summarize
results 5122-28-04
Accreditors are not specific in their
requirements for documentation in
the assessment of
8 client/parent/guardian service
Client/Family/Guardian preferences. However, client's
Expression of Service willingness to discuss and list their
Preferences: Behavioral DTX4 preferences does speak very
Health Clinical and 5122-27- PC.2.140 MH3 directly to their willingness to
Rehabilitative 05(A) RI.2.30 RTX4 2.B.9.d,f P s participate in those services.
62
Child/Adolescent Diagnostic Assessment Update
See above. Payers and
accreditors both are looking for
Client/Family/Guardian evidence that the client is willing
9
Expression of Service and able to participate in their
Preferences: Environmental PC.2.140 care. This documentation provides
Supports RI.2.30 2.B.9.d,f P s support for this.
This is where the primary case for
client benefit is made by listing
prioritized needs (hopefully
resulting form a negotiation
between the clinician and client or
10 their representatives) and the level
of treatment that would be most
effective in meeting those needs.
This section also provides a
secondary case for participation if
Treatment Assess- client assisted in development of
Recommendations/Assessed ment list. Medicaid requires that this list
Needs; Check box for Matrix; be tied to the diagnosis as well as
Deferred or Referred 02(A) (B)(1)(c ) 08-K-3r IM.6.20 RPM7 2.B.10 P s P the treatment plan.
* Note: For this element field,
5122-29-04(B)(1)(e) lists the
elements to be included when
clinically indicated, as determined
by the provider.
May be needed to rule out
11 additional diagnoses or to confirm
the current diagnosis especially if
a new clinical picture is emerging.
Medicaid does require that
additional diagnostic work be done
only if it can provide unique and
useful information that cannot be
Assess- obtained at a lesser expense. Most
ment payers want providers to follow the
Further Evaluations Needed 02(A) (B)(1)(e)* 08-K-3r IM.6.20 Matrix 2.B.10 s same guideline.
63
Child/Adolescent Diagnostic Assessment Update
This is where the primary case for
client benefit is made by listing
prioritized needs (hopefully
resulting from a negotiation
between the clinician and client or
their representatives) and the level
12 of treatment that would be most
effective in meeting those needs.
This section also provides a
secondary case for participation if
client assisted in development of
list. And, finally, both participation
and ability to benefit are heavily
tied into the medical necessity of
services. Medicaid requires that
Level of Care/Indicated (A); this list be tied to the diagnosis as
Services Recommended (B)(1)(c ) 05-F-6 PC.2.70 2.B.10 P s P well as the treatment plan.
RPM7 Especially important if client is an
13 Client/Guardian/Family MH3 2.B.8 adult with a legal representative.
Response to PC.4.50; DTX4 4.A.1.q Speaks directly to client's
Recommendations 60 CM4 4.D.6.q P willingness to participate.
The ISP should reflect the most
recent information on the client
14 including any changes to
For Updates-Change in ISP diagnostic or assessment
required checkbox information.
Needed for billing-Auditor will look
to make sure that diagnosis
changes and other information has
15 been completed by someone with
the training to be able to do so.
The assessment must be signed
Provider 06-I-5;08- IM.6.10; RPM 2.B.7 by a diagnosing professional, if the
Signature/Credential/Date 02(G)(4) (D)(1) K-4 HR.5.10 7.04 2.G.2 diagnosis is changed or modified.
16 Supervisor Signature (if IM.6.10; RPM 2.B.7 See above. May be needed for
applicable)/Credential/Date 02(G)(4) (D)(2) 08-K-4 HR.5.10 7.04 2.G.2 billing.
Provider Signature rendering
17 diagnosis if different than 06-I-5;08- IM.6.10; 2.B.7 See above. May be needed for
above/Credential/Date 02(G)(4) K-4 HR.5.10 2.G.2 billing.
18 Physician Signature (if (D)(1)(a); IM.6.10; 2.B.7 See above. May be needed for
applicable)/Credential/Date 02(G)(4) (2)(a) 08-K-4 HR.5.10 2.G.2 billing.
Date of service is required on the
claim. Medicaid references the
19
06-N-2;08- DMH requirements for this
Date of Service 02(G)(1) K-4 documentation.
20 Staff ID Number
64
Child/Adolescent Diagnostic Assessment Update
21 Needed for billing; required by
Location Code Yes MACSIS
Please see manual for cautions re:
what to consider before entering a
22
billing code for this service. Payer
rules must be understood and
Prcdr Code Yes closely followed.
Depending on the code used for
billing this may or may not be a
23 time based service. However,
service times are important for
compliance reasons, e.g., to
Modifier (1-4) Yes identify duplicate claims.
24 Needed for billing; required by
Start Time 02(G)(2) 06-N-3 MACSIS
25 Stop Time 02(G)(3) 06-N-3
26 Needed for billing; required by
Total Time 02(G)(3) 06-N-3 MACSIS
27 Needed for billing; required by
Diagnostic Code 06-I-2 P MACSIS
65
Compliance Grid for Ohio SOQIC Forms
Initial Psychiatric Evaluation
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-04 See Note
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
***Note: ODADAS does not
require that a psychiatric
evaluation be completed.
Therefore, ODADAS regulations
are not addressed in the grid for
this form. Providers should refer to
ODADAS rule 3793:2-1-08 (K)
regarding assessment service for
1 further information about required
elements.
All payers require that the client be
identified. Also, National
Accreditors all require sufficient
identifying information. Best
practice requires that the name or
client number both of the individual
appear at the top of every page in
IM.6.2 case the record becomes
Client Name (First, MI, Last) Yes 0 disassembled.
Use of an ID number would allow
2 the PHI to be de-identified as
Client No. defined by HIPAA.
3 Date
66
Initial Psychiatric Evaluation
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-04 See Note
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
The accrediting agencies do not
require a separate psychiatric
assessment unless it is pertinent
to the client's needs and do not
have specific documentation
standards to guide the form. The
standards listed here are for a
general diagnostic assessment.
CARF does require that psychiatric
services be available for certain
programs but does not specify the
content of the psychiatric
assessment. DMH does require a
4 diagnostic assessment but not a
separate psychiatric assessment
and only requires that content of
the record has to include an
assessment of all findings. But in
the 5122-29-05 Medication
Somatic Service Rule a psychiatric
assessment is required if clinically
indicated. Medicare has specific
CPT codes for psychiatric
diagnostic assessment and
content requirements. ODADAS
does not require a separate
psychiatric assessment but does
require a diagnostic assessment
IM.6.2 that must be current within specific
Age 0-2 RPM 7 s time frames.
5 IM.6.2
Sex 0-2 RPM 7
6 IM.6.2
Race 0-2 RPM 7
7 IM.6.2
Marital Status 0-2 RPM 7
67
Initial Psychiatric Evaluation
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-04 See Note
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
Would be required by Medicare
8 and other payers if the service that
RPM was provided and subsequently
Referred by 7.02 billed was a consultation.
If the client is unable to adequately
communicate their history and
current status or problems, others
involved with the client can be
sources of this information. If the
client cannot be their own
historian, then a payer may
question the ability of the client to
participate in their care.
Documentation should clear this
up for the payer, e.g. "The client's
mom provided the information but
9 the client appeared attentive and
engaged and did participate in
some limited play. Client will be
assigned to a play therapist"; or,
"Client's house worker provided
much of the background
information because client has
difficulty expressing themselves in
English. Client does understand
English however and was attentive
during the session. Client will be
assigned to a Spanish speaking
therapist." Medicare allows for the
information to come from others,
without the client present.
Present at Session- client Medicaid allows for others to be
only or if others must be the source of information, but the
identified s client must be present.
68
Initial Psychiatric Evaluation
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-04 See Note
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
National accreditors don't list
information needed specifically in
PC.2.1 presenting problem or in
10 0; CRI2.03; diagnostic overall, but want info
PC.2.7 DTX3.02; gathered as determined by the
0; FPS3.03; provider and as appropriate and
Presenting Psychiatric IM.6.2 MH2.01; necessary to assist in assessment
Problem/AOD History (B)(1)(b) 08-K-3a 0 PSR2.02 2.B.9 P and treatment planning.
History of familial behavioral health
PC.2.1 problems may impact the
0; diagnostic decisions made by
PC.2.6 clinical/medical staff and may also
11 0; impact treatment decisions
Family Psychiatric/AOD PC.2.7 especially those that require
History of: Checkboxes for 0; Assess- interventions and support by family
multiple diagnoses and one (B)(1)(e)xxv IM.6.2 ment members to keep clients in lower
box for other/comments i 0 Matrix 2.B.9 P levels of care.
Past Psychiatric History
Checkbox for psychiatrist if
they have reviewed the past
12 psychiatric history in the
diagnostic assessment and Psychiatrist should also initial the
will not be filling out this part form they reviewed to make sure it
of the assessment or will be can be identified and/or should
documenting a complete enter date and name of clinician
psychiatric history in the who completed the form they
space available. reviewed.
PC.2.6
0;
PC.2.7 May have some diagnostic
13
0; Assess- importance. May indicate need for
Past psychiatric history: (B)(1)(e)xxv PC.3.1 ment more intensive programming if
Hospitalizations i 10 Matrix 2.B.9.g s client is in a rapid cycle.
PC.2.6
0;
PC.2.7
14
0; Assess-
Past psychiatric history: (B)(1)(e)xxv PC.3.1 ment CARF is very prescriptive in this
Outpatient Treatment i 10 Matrix 2.B.9.g area- see standard.
69
Initial Psychiatric Evaluation
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-04 See Note
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
Psychiatrist should also initial the
form they reviewed to make sure it
can be identified. If this
assessment is going to be billed as
a consultation it is recommended
that this form be completely filled
out and that there not be reference
15
to another form. If the
Current Medications psychiatrist/ARNP does rely on
Checkbox for psychiatrist if another document and will not
they have reviewed the completely fill out this form as a
medications and other result, the Psychiatric Evaluation
documents and will not list should never be released without
them again or will document the accompanying referenced
a complete listing below. P document.
PC.2.6
0;
PC.2.7
0; Multiple co-morbidities may
PC.3.1 indicate a need for more intensive
16
Current Medication(s) List: 10 interventions, closer oversight with
Current Medications, PC.2.3 Assess- psychiatric medication
Rationale, 0; ment management, and/or the need to
Dosage/Route/Frequency, (B)(1)(e)xxv PC.2.4 Matrix consult with other medical
Compliance i 0 RPM 7 2.E.3 P providers.
PC.2.6
0;
PC.2.7
0;
PC.3.1
17
10
PC.2.3
Comments on any side 0;
effects to medications or (B)(1)(e)xxv PC.2.4 2.E.4.d,5
checkbox "None Reported" i 0 RPM 7 .d,8 P
PC.2.6
0;
PC.2.7
0;
18
PC.3.1
10
Adverse Drug (B)(1)(e)xxv PC.2.3 2.E.5.d;
Reactions/Allergies i 0; RPM 7 2.B.9.v
70
Initial Psychiatric Evaluation
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-04 See Note
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
PC.2.4
0
Psychiatrist should also initial the
form they reviewed to make sure it
can be identified. If this
assessment is going to be billed as
a consultation it is recommended
that this form be completely filled
Additional out and that there not be reference
19
Psychiatric/Social/AoD to another form. If the
History Checkbox for psychiatrist/ARNP does rely on
physician if they have another document and will not
reviewed past social and completely fill out this form as a
psychiatric history in the result, the Psychiatric Evaluation
diagnostic assessment and should never be released without
will not be completing this the accompanying referenced
section document.
Additional
Psychiatric/AoD/Social
20
History (cue to psychiatrist to Assess-
include education, military, (B)(1)(e)ii;x PC.2.1 ment
marital, legal, etc.) xivxv;xvi 40 Matrix 2.B.9 s May support certain diagnoses.
71
Initial Psychiatric Evaluation
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-04 See Note
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
Medical health problems may add
to the complexity of medical
decision- making for evaluation
and management coding.
Psychiatrist should also initial the
form they reviewed to make sure it
can be identified. If this
assessment is going to be billed as
21 a consultation it is recommended
that this form be completely filled
out and that there not be reference
to another form. If the
Health History psychiatrist/ARNP does rely on
Checkbox for physician if another document and will not
they have reviewed the completely fill out this form as a
health history completed by result, the Psychiatric Evaluation
client or will document should never be released without
complete Health Hx in the accompanying referenced
narrative section document.
Assess-
22 ment
Pertinent/Additional Health (B)(1)(e)xxv PC.2.5 Matrix
History (Past and Present) i 0 RPM 7 2.B.9.h P
The mental status exam provides
evidence of medical necessity by
looking at current symptomology,
evidence of client participation by
23 looking at the degree of
impairment the client has in
communicating and being
communicated to and the potential
Assess- benefit by identifying symptoms
PC.2.7 ment that can be addressed by
Mental Status Exam (B)(1)(e)ivi 0 Matrix 2.B.9.k P P P treatment.
24 Elaboration of positive
mental status findings s
72
Initial Psychiatric Evaluation
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-04 See Note
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
To meet the medical necessity
requirements of all payers there
must be one or more mental health
diagnoses which are the focus of
treatment. An auditor will look at
the diagnosis in combination with
the clinical summary, mental
status, and functional status
information to determine Medical
Necessity for the level of care and
services listed on ISP. Payers
differ as to whether they require
DSM or ICD codes for diagnosing.
In addition to mental health
25 diagnoses, accurately listing other
medical co-morbidities is important
as they may impact payer
decisions on how often and
intensely the client may need to be
seen. For example, a diabetic
client on certain psychotropics
which include development of a
type of diabetes or exacerbation of
existing diabetes as a side effect
may require additional
coordination of care, more
frequent medication management
sessions and additional and more
frequent lab testing or other
diagnostics. Most accreditors
DTX3.03; require a diagnosis and like payers
IM.6.2 PSR2.03 may require either DSM or ICD
Diagnoses- DSM-IV- Axis I 06(F)(2)(b) (B)(1)(c ) 06-F6; 06-I 0 ;MH2.02 2.B.9.i P coding.
26 Diagnoses- DSM-IV- Axis II
27 Justification for ALL
diagnoses
28 Diagnoses- DSM-IV- Axis III
29 Diagnoses- DSM-IV- Axis IV
73
Initial Psychiatric Evaluation
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-04 See Note
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
Diagnoses- DSM-IV- Axis V:
30 Current and highest in past
year GAF
31 Differential Diagnosis (if any)
Formulation/Dynamics
Medications Prescribed:
name, dosage, frequency,
32 route, amount, refills, MM.1.
new/continuing/discontinued/ 10; 2.B.9.u;
rationale. Check box for IM.6.2 2.E.3;
"None Prescribed" 5122-29-05 0 RPM 3 2.G.3.h P
Explained Rationale
Checkbox for physician to
confirm they have reviewed
33 rationale for medication
choices, and discussed CARF specifically requires this for
risks, benefits and every medication prescribed. Best
alternative treatment with practices support the need for
client or parent/guardian. 5122-29- medication education including the
Check boxes and narrative 05(A)(3), MM.1. RPM 2.E.8,9, need to explain and offer
section 02(G)(6) (5) 10 3.02 10 s s alternative treatments.
5122-29-
34 Client/Guardian Response- 05(A)(3),
to above explanation 02(G)(7) (5) s s
May support higher E & M codes
Laboratory Tests Ordered. by adding complexity to medical
35
Check box for "None IM.6.2 RPM decision-making for this and future
Ordered" 02(G)(6) 0 7.03 2.B.10.b s visits.
74
Initial Psychiatric Evaluation
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-04 See Note
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
This section should include the
strategy and plan for the next and
possibly some of the additional
treatment interventions. This
36 plan/strategy may be limited to
medical somatic services or may
encompass all services the client
is receiving. It is usually very short
term look at the client- "When
Follow-up Plan with cues for does the client need to be seen
referrals, labs, visit 02(A); IM.6.2 again?" "What should happen in
frequency, etc. 02(G)(6) (B)(1)(c ) 0 RPM 7 2.B.10.b P s P the meantime?"
Other Considerations for
Non-Pharmacological
37
Services in Treatment Plan.
Check box for "None
indicated at this time"
IM.6.1
Signature of Psychiatrist or 0;
38
ARNP/Credential/Date of 5122-29- HR.5.1 RPM 2.B.7;
Signature 02(G)(4) 05(D) 0 7.04 2.G.2 Required for billing
DMH/Medicaid: Initial diagnostic
(which could be completed by a
Psychiatrist or ARNP using this
form) must be completed prior to
39 services delivery except for crisis
interventions and emergency
medication management. Date of
service is required on the claim.
Medicaid references the DMH
requirements for this
Date of Service 02(G)(1) documentation.
40 Staff ID No.
41 Needed for billing; required by
Location Code Yes MACSIS
42 Needed for billing; required by
Prcdr. Code Yes MACSIS
75
Initial Psychiatric Evaluation
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-04 See Note
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
43 Needed for billing; required by
Modifier (1-4) Yes MACSIS
The code for this service is not a
time based code in Medicare or for
many other payers. However,
44 recording accurate times can
provide a defense in the face of an
audit and does provide additional
compliance benefits in identifying
duplicate claims, confirmation that
Start Time 02(G)(2) service was completed, etc.
45 Stop Time 02(G)(3)
46 Needed for billing; required by
Total Time 02(G)(3) MACSIS
47
Needed for billing; required by
Diagnostic Code P MACSIS
76
Compliance Grid for Ohio SOQIC Forms
Crisis Intervention Assessment and Plan
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-10 See Note
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
***Note: ODADAS does not
require a specific crisis
intervention assessment and plan.
Therefore, ODADAS regulations
are not addressed in the grid for
this form. Refer to ODADAS rule
3793:2-1-08 (K) for requirements
regarding assessment and rule
3793:2-1-08 (L) for requirements
1
regarding crisis intervention
services. All
payers require that the client be
identified. Also, National
Accreditors all require sufficient
identifying information. Best
practice requires that the name or
client number both of the individual
appear at the top of every page in
IM.6.2 case the record becomes
Client Name Yes 0 disassembled.
Use of an ID number would allow
2 the PHI to be de-identified as
Client Number defined by HIPAA.
77
Crisis Intervention Assessment and Plan
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-10 See Note
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
TJC, CARF and COA do not
require a separate crisis
assessment. CARF states in its
standards that in short term
programs the amount of
information collected may be
limited by time or condition of the
person or the service provided.
3 Intent of standard is to collect an
adequate amount of information to
provide appropriate and safe
services. DMH does have crisis
Presenting Problem/Clinical specific requirements. Medicaid
Narrative (include etiology, does not have specific standards.
severity, and onset [acute vs. Please see the Adult and Child
chronic] of presenting Diagnostic Assessments and ISP
problem; issues since last as well as the Psychiatric
stabilization, if applicable; Assessment for relevant citations
history of previous crises, for Medicaid and the accreditors.
including results) (C )(1)(a) 3.G.2.b;i P The DMH citations are shown.
The mental status exam provides
evidence of medical necessity by
looking at current symptomology,
evidence of client participation by
4 looking at the degree of
impairment the client has in
communicating and being
communicated to and the potential
Mental Status Examination: benefit by identifying symptoms
Complete MSE form or that can be addressed by
Provide Written Narrative (C )(1)(c ) P P P treatment.
5 Past Attempts to Harm Self
or Others (C )(1)(b) P
Current Risk of Harm to Self-
6 check box for level- narrative
required if moderate or high
risk (C )(1)(b) P
78
Crisis Intervention Assessment and Plan
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-10 See Note
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
Current Risk of Harm to
7 Others- check box for level-
narrative required if
moderate or high risk (C )(1)(b) P
Current Medication
Information to Include Speaks to the level and complexity
8 Medical, Psychiatric, OTC, of medical decision making that
Herbal- name of meds, must be made to organize or
rationale, dosage, route, determine treatment needs and
frequency, compliance (C )(1)(b) P P P level of care.
Medical health problems may add
to the complexity of medical
9
decision making that must be
made to determine treatment
Pertinent Medical History (C )(1)(b) P needs and level of care.
Outpatient MH/AoD
10 Treatment-
agency/current/past
(dates)/clinician name (C )(1)(b)
11 Psychiatric Hospitalizations:
hospital, dates, reasons (C )(1)(b)
12 Other comments re: Mental
Health Treatment History (C )(1)(b)
DMH requires a alcohol/drug
screen/assessment as part of the
crisis assessment. IV drug use
13 speaks to a specific need for
medical intervention. Substance
abuse combined with pregnancy
Alcohol/Drug Abuse History: speak to a specific need for
checkboxes (C )(1)(b) P medical intervention.
Alcohol/Drug History-
14 Toxicology Screen
Completed, check box;
Results (C )(1)(b) s
79
Crisis Intervention Assessment and Plan
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-10 See Note
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
Alcohol/Drug History-
15 Presenting with Detox
Issues, check box (C )(1)(b) P
List Drug/Substance/Alcohol
16 including age of first use,
date of last use, frequency of
use, amount and method (C )(1)(b) s
AoD Treatment History-
17 checklist, list dates, provider
and services rendered (C )(1)(b)
18 Other Comments re:
Substance Abuse/Use (C )(1)(b)
19 Describe family
functioning/primary support
An assessment of strengths is
require by DMH in a crisis
20
Strengths/Capabilities/ assessment. Treatment planning
Limitations of Activities of should build, if possible, on these
Daily Living (C )(1)(d) s s strengths.
80
Crisis Intervention Assessment and Plan
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-10 See Note
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
To meet the medical necessity
requirements of all payers there
must be one or more mental health
diagnoses which are the focus of
treatment. An auditor will look at
the diagnosis in combination with
the clinical summary, mental
status exam and functional status
information to determine Medical
Necessity for the level of care and
21 services listed on the Crisis Plan.
Payers differ as to whether they
require DSM or ICD codes for
diagnosing. In addition to mental
health diagnoses, accurately listing
other medical co-morbidities is
important as they may impact
payer decisions on level of care,
e.g. a more medically fragile client
may require hospitalization to
contain the crisis, where a non-
medically fragile client might not.
Most accreditors require a
diagnosis and like payers may
Diagnosis- Axis I to V P P require either DSM or ICD coding.
This section is used to record
additional discrete interventions
provided during the crisis
intervention that are not part of the
assessment or the development of
22 the crisis plan. This allows the one
Brief Description of form to be used to describe the
Interventions Provided (if entire intervention with the
applicable). Date, Start Time, exception of medication
Total Time, management services which
Signature/Credentials, Date, should be described on a
Response to Intervention 3.H.5 P P Psychiatric Progress Note.
81
Crisis Intervention Assessment and Plan
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-10 See Note
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
List of Treatment
23 Recommendations/Assessed
Needs to be addressed (C )(1)(e) P P
Wishes/preferences of the
24 individual/parent or guardian,
as appropriate (C )(2) P
Goals- stabilization/linking to
25 appropriate care/assuring
safety/other (C )(2) P P
26 Referred for- checklist (C )(2) 3.H.7 s s s
This list should include actions
already taken which adds to the
27 evidence that a crisis intervention
Action Plan/Follow-Up service was provided- and actions
Instructions Chart- list to be taken- confirmation that a
actions taken and comments (C )(2) plan has been established.
DMH requires that plan needs to
28 If crisis does recur I will: address issue of recurrence but
(statement by client) (C )(2) does not require a client contact.
29 Date Crisis Intervention Plan
Developed
Client signatures are not required
on crisis plans, however, it may be
important clinically to obtain the
30 signature of the client and/or their
Parent/Guardian. A client's refusal
to sign should be documented as
well, either on this form or in a
Client Signature/Date separate note.
31 Parent or Guardian
Signature (if applicable)/Date See above
82
Crisis Intervention Assessment and Plan
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-10 See Note
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
Needed for billing- Auditor will look
to make sure that diagnosis and
clinical summary has been
32 completed by someone with the
training to be able to do so. The
Provider IM.6.1 RPM assessment must be signed by a
Signature/Credential/Date 02(G)(4) (E)(1),(3) 0 7.04 diagnosing professional.
33 Supervisor Signature (if IM.6.1 RPM Medicaid/Medicare: may be
applicable)/Credential/Date 02(G)(4) (E)(4),(5) 0 7.04 needed for billing
34 Co-Provider Signature (if IM.6.1 RPM
applicable)/Credential/Date 02(G)(4) (E)(1),(3) 0 7.04
(E)(1)(a),(2)
35 Physician Signature (if (a),(3)(a),(4 IM.6.1 RPM
applicable)/Credential/Date 02(G)(4) ) (a), (5)(a) 0 7.04
DMH/Medicaid: Initial diagnostic
must be done prior to services,
except crisis and emergency
36 meds. Date of service is required
on the claim. Medicaid references
the DMH requirements for this
Date of Service 02(G)(1) documentation.
37 Staff ID No.
38 Needed for billing; required by
Location Code Yes MACSIS
39 Needed for billing; required by
Procedure Code Yes MACSIS
40 Needed for billing; required by
Modifier (1-4) Yes MACSIS
41 Needed for billing; required by
Start Time 02(G)(2) MACSIS
42 Stop Time 02(G)(2)
43 Needed for billing; required by
Total Time 02(G)(3) MACSIS
44 Needed for billing; required by
Diagnostic Code P MACSIS
83
Compliance Grid for Ohio SOQIC Forms
Individualized Service Plan
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-27-05 3793:2-1-06
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
All payers require that the client be
identified. Also, National
Accreditors all require sufficient
identifying information. Best
1 practice requires that the name or
client number both of the individual
appear at the top of every page in
IM.6.2 case the record becomes
Client Name (First, MI, Last) Yes F-1 0 disassembled.
Use of an ID number would allow
2 the PHI to be de-identified as
Client No. F-1 defined by HIPAA.
All of the accreditors or the payers
3 PC.4.2 require that there be goals but do
Goal No. K-4 0-4.90 2.C.3.a not require that they be numbered.
Linked to Treatment
Recommendation No. from
4
DA, DA Update, Crisis
Intervention Plan, Psychiatric This link should be obvious and
Evaluation or Other (A) 2.C.2.b P strong
DMH/Medicaid/ODADAS requires
that the plan be completed within a
certain period of time and be
5 reviewed periodically. Dates would
be needed to confirm compliance
with this requirement. Medicare
requires a current treatment plan
Start Date 2.C.3 so again dates are needed.
6 Target Completion Date K-5 2.C.3 See above
7 Adjusted Target Date See above
PC.4.4
8
Reason for Adjustment (C ) 0 s P
84
Individualized Service Plan
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-27-05 3793:2-1-06
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
The collaborative goal should be
used to write the client's desired
results in clinical terms to support
medical necessity. This does not
9 mean that the wording of the goal
has to be jargon that cannot be
CM4.30 understood by the client but rather
PSR3.04 that casual and slang terms are
MH3.02 removed and the goal can be
RTX4.01 easily linked to stated needs and
State Goal below in PC.4.2 DTX4.03 treatment recommendations from
collaboration with client (A)(2) K-4 0 RPM7.02 2.C.3 P the Diagnostic Assessment.
10 CM4.30
PSR3.04 DMH and the accreditors require
MH3.02 client participation but do not
Desired Results in client's PC.4.5 RTX4.01 require each objective be listed in
words 0 DTX4.03 2.C.3 P the words of the client
11 client has reviewed- check PC.4.5
yes/no (A)(4) 0 2.C.3.a.1 s See above
12 PC.4.5
Client agrees- check yes/no (A)(2) 0 2.C.3.a.2 P See above
ODADAS and COA require client
13 signatures on the overall treatment
Client's Initials for each goal s plan.
14 Strengths and How They Will PC.4.4
Be Used to Meet Goal 0 2.C.3.a.5 s
Defines some of the community
support and/or counseling services
that will be needed to improve
15
skills and/or knowledge of the
PC.4.4 client to assist them in reaching
Skills/Knowledge Needed (A)(1) & (2) 0 2.C.3.a.5 P s their goal.
85
Individualized Service Plan
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-27-05 3793:2-1-06
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
16 MH3.04
DTX4.06
Natural/Community Supports PC.4.6 PSR3.06 Provides case for community
Needed (A)(2) 0 CM4.05 2.C.2.b P s support services.
The objectives which address the
shorter term activities targeted
towards improving functional
status speak more directly to
medical necessity than do the
goals which are longer term and
17 may not relate directly to this level
of care. The objectives should
relate directly to the problem list
developed in the clinical summary.
Objectives are critical because
goals may not ever be reached at
certain levels of care but clients
who meet certain objectives can
and will move on to lower levels
PC.4.2 RPM and progress through the system
Objective No. (A)(1) & (2) K-5 0 7.02 2.C.3.b P and towards their overall goals.
DMH/Medicaid/ODADAS requires
that the plan be completed within a
certain period of time and be
18 reviewed periodically. Dates would
be needed to confirm compliance
with this requirement. Medicare
requires a current treatment plan
Start Date (A)(2) 2.C.3.b so again dates are needed.
19 Duration K-6 2.C.3.b
20 Client will: Narrative
86
Individualized Service Plan
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-27-05 3793:2-1-06
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
Parent/Guardian/Community/
21 Other will: check box and
space for narrative
22 MH3.02 These should describe services
Therapeutic DTX4.03 and should reflect a service
Intervention/Service PSR3.05 strategy appropriate for the
Description/Frequency/ PC.4.2 RTX4.01 diagnosis, clinical picture and
Provider 02(G)(6) (A)(3) K-6 0-4.90 CM4.03 2.C.3.b P functional status of the client.
23 CM4.30
PSR3
MH3.02
Actual Date of Goal RTX4.01
Completion DTX4.03
24 CM4.30
PSR3
MH3.02
RTX4.01
Goal Discontinued Date DTX4.03
87
Individualized Service Plan
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-27-05 3793:2-1-06
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
DMH requires that if client refuses
or is unable to participate in
service planning the reasons for
this be documented. If this is a
discontinuation of a goal for other
25 reasons, especially if there is not
agreement between the clinician
and the client to discontinue this
goal, the client should be advised
of any rights to appeal the decision
MH3.06 and documentation of the reasons
DTX4.08 for discontinuation and the client's
RTX4.04 response should be contained in
Reason for Discontinuation (A)(5) PSR3.08 the medical record.
Listing the names, contacts and
services being provided by others
is important for case coordination
and avoidance of duplicate
services. Also by recognizing
26 others as providers the provider
and client can begin to determine
who the appropriate payer is for
certain of the services listed on the
treatment plan. Not all services
listed can or should be the
Other Agencies Involved: responsibility of the mental health
agency, contact name and PC.4.9 and substance abuse systems or
title, services provided 0 2.C.2.f s the federal health programs.
27 AoD (Only): Adult Level of
Care- checkboxes K-2
28 AoD (Only): Youth Level of
Care- checkboxes K-2
Level of PC.15.
29 Care/Transition/Discharge 10 & DMH requires that anticipated
Plan: Criteria (A)(2) K-2 15.20 2.C.3 P treatment outcomes be listed.
88
Individualized Service Plan
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-27-05 3793:2-1-06
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
30 Anticipated Date of This should relate to the target
Discharge dates of objectives and goals.
Most accreditors require evidence
of client participation. A signature
may assist an organization in
31 MH3.02 meeting this requirement. Date
DTX4.03 provides evidence that treatment
PSR3.04 plan is current. ODADAS and COA
RTX4.01 require the client's signature on
Client Signature/Date K-7 CM4.03 P the treatment plan.
Client Provided Copy of ISP:
32 Checkbox and space for
client initial
For children and legal
representatives of adults- most
accreditors encourage and DMH
33 requires as appropriate family
participation in treatment planning.
The signature may assist an
Parent/Guardian Signature organization in meeting this
(if applicable) Date P requirement.
The primary provider must have
sufficient credentials to supervise
34 all services ordered on the
treatment plan or must secure
Provider IM.6.1 RPM signature of credentialed individual
Signature/Credential/Date 02(G)(4) (A)(6) K-8 0 7.04 who has the appropriate license.
35 Supervisor's Signature (if IM.6.1 RPM
applicable)/Credential/Date 02(G)(4) (A)(6) 0 7.04 See above
89
Individualized Service Plan
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-27-05 3793:2-1-06
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
This serves as the authorization
for med/somatic treatment.
Medicare requires a physician's
36 signature unless client receiving
only services provided by
independently licensed social
Physician's Signature (if IM.6.1 RPM workers, CNS's, psychologists and
applicable)/Credential/Date 02(G)(4) (A)(6) 0 7.04 others with Medicare numbers.
90
Compliance Grid for Ohio SOQIC Forms
Individualized Service Plan Review
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-27-05 3793:2-1-06
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
All payers require that the client be
identified. Also, National
Accreditors all require sufficient
identifying information. Best
1 practice requires that the name or
client number or both of the
individual appear at the top of
IM.6.2 every page in case the record
Client Name (First, MI, Last) Yes F-1 0 becomes disassembled.
Use of an ID number would allow
2 the PHI to be de-identified as
Client No. F-1 defined by HIPAA.
DMH/Medicaid/ODADAS requires
that the plan be completed within a
certain period of time and be
3 reviewed periodically. Dates would
be needed to confirm compliance
with this requirement. Medicare
requires a current treatment plan
Review Date so again dates are needed.
4 ISP Date
91
Individualized Service Plan Review
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-27-05 3793:2-1-06
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
CARF and TJC would like the
service plan revised periodically
for continuing relevancy and
modification as needed. ODADAS
does not have specific
requirements for ISP update, only
that agency must have policies
5 that specify criteria and time
frames for this process. Refer to
ODADAS standard 3793:2-1-06
MH3.05, (L). DMH requires periodic review
3.06 and at least annually with evidence
RTX4.04 of active participation of client. A
Review of Progress (to PSR3.07 review would also be required if a
include outcomes and ,3.08 recommended service is
progress on each goal, PC.4.4 DTX4.08, terminated, denied or no longer
objective) (C) L 0.3 4.09 2.C.6 available to the client.
MH3.05,
3.06
6 RTX4.04
PSR3.07
,3.08
Revision to ISP: no change, PC.4.4 DTX4.08,
revision, new (C ) L 0.3 4.09 2.C.6
MH3.05,
3.06
7 RTX4.04
PSR3.07
,3.08
PC.4.4 DTX4.08,
Comments on Revisions (C ) 0.3 4.09 2.C.6
92
Individualized Service Plan Review
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-27-05 3793:2-1-06
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
Listing the names, contacts and
services being provided by others
is important for case coordination
and avoidance of duplicate
services. Also by recognizing
others as providers the provider
8
and client can begin to determine
who the appropriate payer is for
specific services listed on the
treatment plan. Not all services
listed can or should be the
Additional Agencies responsibility of the mental health
Involved: agency, contact PC.4.9 or substance abuse systems or the
name, title, services provided 0 s federal health programs.
Level of
Care/Transition/Discharge
9
Criteria/Continued Stay PC.15.
Review for ODJFS 10 & DMH requires that anticipated
Residential 15.20 P treatment outcomes be listed.
10 AoD Only Adult Level of
Care K-2; 05-F
11 AoD Only Youth Level of
Care K-2; 05-F
Most accreditors require evidence
of client participation. A signature
may assist an organization in
12 meeting this requirement. Date
provides evidence that treatment
MH3.06 plan is current. ODADAS requires
PSR3.08 the client's signature on the
Client Signature/Date DTX4.09 P treatment plan.
Client Provided Copy of ISP:
13 Checkbox and space for
Client Initials
93
Individualized Service Plan Review
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-27-05 3793:2-1-06
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
For children and legal
representatives of adults- most
accreditors encourage and DMH
14 requires as appropriate family
participation in treatment planning.
The signature may assist an
Parent/Guardian Signature (if organization in meeting this
applicable)/Date P requirement.
The primary provider must have
sufficient credentials to supervise
15 all services ordered on the
treatment plan or must secure
Provider IM.6.1 RPM signature of credentialed individual
Signature/Credentials (C )(1)(c ) L 0 7.04 who has the appropriate license.
16 Supervisor Signature (if RPM
applicable)/Credential/Date (C )(1)(c ) 7.04 See above
17
Authorization for med/somatic
treatment. Medicare requirement
unless client receiving only
services provided by
independently licensed social
workers, CNS's, psychologists,
Physician Signature (if RPM and others with Medicare
applicable)/Credential/Date 7.04 numbers.
94
Compliance Grid for Ohio SOQIC Forms
Psychiatric/Pharmacological Management Plan
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-05 See Note
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
***Note: ODADAS does not
require a specific
Psychiatric/Pharmacological Plan.
Therefore, ODADAS regulations
are not addressed in the grid for
this form. Refer to ODADAS rule
3793:2-1-06 (K) for requirements
regarding individualized treatment
1 plans.
All payers require that the client
be identified. Also, National
Accreditors all require sufficient
identifying information. Best
practice requires that the name or
client number or both of the
individual appear at the top of
every page in case the record
Client Name Yes IM.6.20 becomes disassembled.
Use of an ID number would allow
2 the PHI to be de-identified as
Client No. defined by HIPAA.
DMH and the accreditors require
3 client participation but do not
State Desired Results in require each goal listed in the
Client's Own Words PC.4.50 2.C.3 words of the client.
DMH/Medicaid/ODADAS requires
that the plan be completed within
a certain period of time and be
reviewed periodically. Dates
4 would be needed to confirm
compliance with this requirement.
Medicare requires a current
treatment plan so again dates are
Start Date 2.C.3 needed.
95
Psychiatric/Pharmacological Management Plan
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-05 See Note
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
The collaborative goal should be
used to write the client's desired
results in clinical terms to support
medical necessity. This does not
5 mean the wording of the goal has
to be jargon that cannot be
CM4.30 understood by the client, but
State Goals in Collaboration PSR3.04 rather that casual and slang terms
with Client as Identified on MH3.02 are removed and the goal can be
form dated____: RTX4.01 easily linked to stated needs and
Checkboxes plus room for DTX4.03 treatment recommendations from
additional goals not listed (A)(2) PC.4.20 RPM7.02 2.C.3 P the Diagnostic Assessment.
The objectives which address the
shorter term activities targeted
towards improving functional
status speak more directly to
medical necessity than do the
goals which are longer term and
6 may not relate directly to this level
of care. The objectives should
relate directly to the problem list
developed in the clinical summary.
Objectives are critical because
goals may not ever be reached at
certain levels of care but clients
who meet certain objectives can
Objectives: Checkboxes plus and will move on to lower levels
room for additional objectives and progress through the system
not listed PC.4.20 RPM7.02 2.C.3.b P and towards their overall goals.
96
Psychiatric/Pharmacological Management Plan
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-05 See Note
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
Therapeutic
7 Intervention/Provider/ MH3.02
Frequency/Duration: DTX4.03 These should describe services
Checkboxes plus room for PSR3.05 and service strategy appropriate
additional entries in each PC.4.20- RTX4.01 for diagnosis, clinical picture and
section (A)(3) 4.90 CM4.03 2.C.3.b P functional status of the client.
Referrals/Additional
Evaluations: Checkboxes
8
plus room for additional
referrals/evaluations not
listed PC.4.90 2.C.3
Explained rationale, benefits,
9 risks and treatment CARF specifically requires this for
alternatives to/for client RPM3.02 2.E.10 s s every medication prescribed.
10 Client/Guardian Response: PC.4.40,
Checkboxes 02(G)(7) 50, 60 2.E.11 P
If client refuses plan, DMH and Medicaid do not pay for
11 describe plan for involuntary services in outpatient
continuation of services (A)(5) setting except in very rare cases.
Most accreditors require evidence
12 MH3.02 of client participation. A signature
DTX4.03 may assist an organization in
PSR3.04 meeting this requirement. Date
RTX4.01 provides evidence that treatment
Client Signature/Date CM4.03 P plan is current.
97
Psychiatric/Pharmacological Management Plan
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-05 See Note
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
For children and legal
representatives of adults- most
accreditors encourage and DMH
13 requires as appropriate family
participation in treatment planning.
The signature may assist an
Parent/Guardian Signature (if organization in meeting this
applicable)/Date P requirement.
A physician and/or APRN must
sign the plan if medication
services are ordered or other med
somatic services are ordered that
require their level of licensure.
The nursing signature line is
available for two reasons: (1) For
Medical Somatic Plans where
14 both the nurse and the physician
complete parts of the plan, the
nursing signature line evidences
their involvement in plan
development. (2) Where the only
medical/somatic services ordered
are those requiring an RN. In this
case the nurse can order the
Nursing services under their own license,
Signature/Credential/Date (if RPM a physician or APRN signature is
applicable) 02(G)(4) IM.6.10 7.04 not needed.
15 Physician/APRN
Signature/Credential/Date RPM Required for billing and see
(required) 02(G)(4) IM.6.10 7.04 above.
98
Compliance Grid for Ohio SOQIC Forms
Pharmacologic Management/Psychiatric Progress Note
Please note the issues of medical
necessity/participation and
MCD/CARE Requirements benefit are similar for both
ODADAS, ODMH, Medicaid and most accreditors do not have specific requirements for a psychiatric progress note but Federal and Ohio Medicaid as
only for progress notes in general. Medicare does have specific requirements. well as for Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-27-06 3793:2-1-06
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
All payers require that the client
be identified. Also, National
Accreditors all require sufficient
identifying information. Best
1 practice requires that the name or
client number or both of the
individual appear at the top of
IM.6.2 every page in case the record
Client Name Yes 06-N1 0 becomes disassembled.
Use of an ID number would allow
2 the PHI to be de-identified as
Client No. 06-N1 defined by HIPAA.
If only person present is the
Present at Session: List client, this does not need to be
3 Names of Persons Present; completed. This should be
Client Present or No Show reserved for family members and
checkbox others that attend.
Interim history- (include
review of client's condition,
medications and include
those pertaining to physical
health, dosages, allergic
4 reactions, effectiveness of
medications, substance
abuse, health changes since
last visit, pregnancy and An auditor would be concerned
lactation status, clients with the impact of
assessment of progress IM.6.2 Assess- treatment/medications on client
related to symptoms, side 0, ment since last visit. All evaluation and
effects and overall PC.2.1 Matrix; 2.E.8, 9, management coding does require
functioning). (A) 06-M, N 50 RPM 3 10 P an interim history.
99
Partial Hospital Progress Note
Please note the issues of medical
necessity/participation and
MCD/CARE Requirements benefit are similar for both
ODADAS, ODMH, Medicaid and most accreditors do not have specific requirements for a psychiatric progress note but Federal and Ohio Medicaid as
only for progress notes in general. Medicare does have specific requirements. well as for Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-27-06 3793:2-1-06
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
The mental status exam provides
evidence of medical necessity by
looking at current symptomology,
Mental status: not as evidence of client participation by
5 complex as on the psych looking at the degree of
assessment- but contains impairment the client has in
standard elements- communicating an being
comments required only on IM.6.2 communicated to and the
areas of concern. Check box 0, Assess- potential benefit by identifying
for No Significant Change PC.2.1 ment symptoms that can be addressed
from Last Visit (B)(3) 50 Matrix P P P by treatment.
Side effects check boxes MM.7. This is a very important risk
6 including 2 "other" boxes and 30 management issue. Documenting
a narrative comments MM.6. side effects is consistent with
section 10 2.E.8.b P good medical practice.
7 AIMS Check- checkboxes re:
need for AIMS check 2.E.8.c
May show need for additional
MM.7. interventions if abnormal. May
8
Summary of key laboratory 30 also show client benefit, e.g.
results. Check box if none MM.6. lithium levels and/or others
reported. 08-R 10 2.E.10 P s reaching therapeutic dosages.
May speak to client's ability to
9 Check box- Were results participate. Shows provider
shared with client? (B)(3) 2.E.10 s engaging client in their care.
IM.6.1
0
10
Other Measurements: vital IM.6.2 May add complexity of visit for
signs, height/weight (A) 06-M, N 0 P E&M coding
Medication prescribed indicate a
Medications, if any, IM.6.2 medical treatment intervention-
11 prescribed- name/ dosage/ 0 needed to code 90862 and many
route/frequency/amount/refill MM.3. E&M codes. For ODADAS this
s/new/continuing/discontinue 20 includes all medications with
d; check box- None MM.1. exception of methadone which is
Prescribed 02(G)(6) 5122-29-05 08-S3 10 2.E.3 P a separate service category.
100
Partial Hospital Progress Note
Please note the issues of medical
necessity/participation and
MCD/CARE Requirements benefit are similar for both
ODADAS, ODMH, Medicaid and most accreditors do not have specific requirements for a psychiatric progress note but Federal and Ohio Medicaid as
only for progress notes in general. Medicare does have specific requirements. well as for Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-27-06 3793:2-1-06
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
May provide evidence that client
either is or is not responding to
12 the medications and possibly
Rationale for new, changed need to change treatment
or discontinued medications 02(G)(6) 5122-29-05 08-S3 s protocol.
13 OMAP Client: Check box, if This is a best practice and not a
yes, stage requirement.
Check box- explained
rationale, benefits, risks and Shows attempt to engage client in
14
treatment alternatives to participation in treatment and
client (if new or changed MM.6. their ability to absorb treatment
medication) 02(G)(7) (B)(3) 10 2.E.10 s s related information.
Check box- client/guardian
response: understands
15 information, does not
understand, agrees with
medication, refuses MM.6.
medication 02(G)(7) (B)(3) 10 s s
CARF requires that progress
notes are able to readily identify
the goals and objectives that
were achieved or revised during
the session, as well as any
significant events or changes in
person's life and specific services
16 provided that support the
individual's service plan; OAC
5101:3-27-02 (G)(6); the
Therapeutic interventions therapeutic strategy should be
provided, response to addressed for Medicare;
intervention, progress toward ODADAS wants summary of what
goals/objectives (e.g., happened during the intervention;
medication monitoring, RX, OAC 5101:3-27-02 (G)(7): this
review of lab tests, 02(G)(6), (B)(2), IM.6.2 2.C.7 should reflect the individual's
education, support) (7) (B)(3) 06-N4, 5 0 2.E.10 P P P response to the intervention
101
Partial Hospital Progress Note
Please note the issues of medical
necessity/participation and
MCD/CARE Requirements benefit are similar for both
ODADAS, ODMH, Medicaid and most accreditors do not have specific requirements for a psychiatric progress note but Federal and Ohio Medicaid as
only for progress notes in general. Medicare does have specific requirements. well as for Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-27-06 3793:2-1-06
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
Speaks to strategy of clinician for
future treatment. Strategy should
be based on current status and
17 response of client. ODADAS
wants narrative to include a
Follow Up Plan with cues; (B)(2), PC.4.2 justification for continuing
Check box for Update AIMS 02(A) (B)(3) 06-N5 0 & 40 P treatment.
Diagnosis is one of the key
18 elements of medical necessity.
Check box- change in Note: ODADAS has no standards
diagnosis P for the psychiatric progress note.
19 Rationale for changed or Makes case for mental illness
additional diagnoses P that treatment will address.
20 Provider 02(A) & IM.6.1 RPM
Signature/Credential/Date 02(G)(4) (B)(4) 06-N6 0 7.04 2.C.7 For billing all payers
Date of service is required on the
claim. Medicaid references the
21
DMH requirements for this
Date of Service 02(G)(1) (B)(1) 06-N2 documentation.
22 Staff ID No.
23 Needed for billing; required by
Location Code Yes MACSIS
24 Needed for billing; required by
Prcdr Code Yes MACSIS
25 Needed for billing; required by
Modifier Yes MACSIS
Depending on the payer and the
service code used to bill, this
service may or may not be a
time-based code. However,
26 recording time does provide
additional compliance benefits,
e.g. identifying duplicate services,
confirmation that service was
Start Time 02(G)(2) 06-N3 completed, etc.
27 Stop Time 02(G)(3) 06-N3
28 Needed for billing; required by
Total Time 02(G)(3) 06-N3 MACSIS
102
Partial Hospital Progress Note
Please note the issues of medical
necessity/participation and
MCD/CARE Requirements benefit are similar for both
ODADAS, ODMH, Medicaid and most accreditors do not have specific requirements for a psychiatric progress note but Federal and Ohio Medicaid as
only for progress notes in general. Medicare does have specific requirements. well as for Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-27-06 3793:2-1-06
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
29
Needed for billing; required by
Diagnostic Code P MACSIS
103
Compliance Grid for Ohio SOQIC Forms
Partial Hospital Progress Note
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-27-06 See Note
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
***Note: ODADAS service level
comparable to Partial Hospital is
Intensive Outpatient services
(IOP), this is a multimodality
service and the Partial Hospital
Note would not be adequate.
Therefore, ODADAS regulations
are not addressed in the grid for
1
this form. IOP can be documented
on the Group Progress Note.
All payers require that the client be
identified. Also, National
Accreditors all require sufficient
identifying information. Best
practice requires that the name or
client number or both of the
individual appear at the top of
IM.6.2 every page in case the record
Client Name (First, MI, Last) Yes 0 becomes disassembled.
Use of an ID number would allow
2 the PHI to be de-identified as
Client No. defined by HIPAA.
3 Date of Service
Medicare has very specific
requirements re: documentation of
Partial Hospital services. Providers
should review these requirements
4 closely. Group name if it reflects
the content of the group might be
Type of Service: Check used by an auditor to determine if
boxes- Group-Name, the group is appropriate for this
Individual Intervention, Client IM.6.2 level of care, e.g.
No Show/Cancelled 0 DTX6.03 2.C.7 social/recreational focus.
5 Time of Day 02(G)(2)
104
Partial Hospital Progress Note
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-27-06 See Note
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
6 From: To: 02(G)(3) Necessary for billing
7 Total Time 02(G)(3) Necessary for billing
Many payers have regulations on
what constitutes a group- there
may be both minimum number of
8 participants and maximum number
of restrictions. Providers should be
aware of these. These restrictions
may be applicable even with co-
Number in Group leaders for the group.
9 Number of Staff Necessary for billing
10 02(G)(5); IM.6.2
Activity/Topic/Interaction 02(A) (B)(2) 0 DTX6.02 2.C.7 s
CARF requires that the progress
notes are able to readily identify
the goals and objectives that were
achieved or revised during the
session, as well as significant
11 events or changes in the person's
life and specific services provided
that support the individual's
service plan. CARF's standard is
typical of the accreditors. Payers
want treatment interventions
Goal/Objective(s) Addressed IM.6.2 closely related to goals and
from ISP 02(A) (A) 0 2.C.7 P objectives.
105
Partial Hospital Progress Note
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-27-06 See Note
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
Therapeutic interventions are the
tools that are used to produce
progress towards individualized
goals and objectives. Payers are
paying for therapeutic
interventions that are delivered by
12 individuals with the expertise to
use them effectively and to
customize them to the client's
individual profile and needs.
Progress notes that do not
Therapeutic Interventions IM.6.2 describe an intervention are not
Provided 02(G)(6) (B)(2) 0 2.C.7 P billable.
The payers expect that the
therapeutic interventions described
above will produce a response
from the client. This response may
be anywhere on the continuum
from negative to neutral to
positive. Auditors will look for a
description of the response and its
relationship to the progress of the
13 individual towards their goals and
objectives in all progress notes.
The auditors do not expect that
each intervention will result in
tangible progress but do expect
that the client's reaction or
response will be used to develop
continuing strategy. OAC 5101:3-
27-02 (G)(7) requires the
Response to Intervention individual's response to the
and Progress Toward Goals IM.6.2 intervention be documented in the
and Objectives 02(G)(7) (B)(3) 0 2.C.7 P s P progress note.
106
Partial Hospital Progress Note
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-27-06 See Note
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
Signatures with the credential of
the provider and date of the
signature are needed for billing.
The auditor will look to make sure
that the person providing the
14 service has the appropriate
credentials. Providers should be
aware of payer rules and should
follow them regarding signatures,
including the need for supervisory
signatures on some documents.
The date should be the date of the
signature, not the date of the
Provider 02(A) & IM.6.1 service unless the note was written
Signature/Credential/Date 02(G)(4) (B)(4) 0 2.C.7 on the same day as the service.
15 Co-provider 02(A) & IM.6.1
Signature/Credential/Date 02(G)(4) (B)(4) 0 2.C.7 See above.
The payer is looking for evidence
that the client is able to participate
in the session and also that, given
the client's current condition, the
16 service is appropriate and clinically
Functioning- May include indicated. For example, a client
mood, affect, behavior, who is actively hallucinating and
cognitive functioning IM.6.1 responding to voices may not
Checkbox- No Significant 0& benefit from or be able to
Change (B)(3) 6.20 P s participate in a therapy group.
107
Partial Hospital Progress Note
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-27-06 See Note
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
If a client is experiencing stressors
or an extraordinary event, the
payer will for the provider's
assessment of how this should
effect today's service and the
17 strategy going forward including
the need to change the treatment
plan. Stressors and extraordinary
events may also explain situations
Stressors/Extraordinary in which the client is non-
Events. Checkbox- None IM.6.2 participatory, inactive or appears
Reported 0 2.C.7 s to be relapsing.
New Issue(s) Presented
Today/Additional
18 Information/Plan (if
applicable) Checkbox- None
Reported, DA Update
Required, New Information, IM.6.2
No DA Update Required (B)(3) 0 2.C.7
Signatures with credential of the
provider and date of the signature
are needed for billing. The auditor
will look to make sure that the
person providing the service has
the appropriate credentials.
19 Providers should be aware of
payer rules and should follow them
regarding signatures, including the
need for supervisory signatures on
some documents. The date should
be the date of the signature, not
the date of service unless the note
Provider 02(A) & IM.6.1 was written on the same day as
Signature/Credential/Date 02(G)(4) (B)(4) 0 2.C.7 the service.
20 Co-provider 02(A) & IM.6.1
Signature/Credential/Date 02(G)(4) (B)(4) 0 2.C.7 See above.
21 Supervisor Signature (if 02(A) & IM.6.1 See above, may be needed for
applicable)/Credential/Date 02(G)(4) 0 2.C.7 billing.
108
Partial Hospital Progress Note
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-27-06 See Note
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
22 Physician Signature (if 02(A) & IM.6.1 See above, may be needed for
applicable)/Credential/Date 02(G)(4) 0 2.C.7 billing.
Please note: billing "incident to"
requires that the physician or other
supervising professional be on-site
23 and that all other rules of "incident
to" billing be followed. In addition,
the content of the group must meet
the definition of the service being
Medicare "Incident to" billed as described in CPT in order
Services Only for it to be Medicare eligible.
Medicare Services Only-
24 Name/Credentials of
Medicare Supervising Required only if service billed
Professional on Site "incident to"
Date of service is required on the
claim. Medicaid references the
25
DMH requirements for this
Date of Service 02(G)(1) documentation.
26 Staff ID No.
27 Needed for billing; required by
Location Code Yes MACSIS
28 Needed for billing; required by
Prcdr Code Yes MACSIS
29 Needed for billing; required by
Modifier (1-4) Yes MACSIS
30 Start Time 02(G)(2)
31 Stop Time 02(G)(3)
32 Needed for billing; required by
Total Time 02(G)(3) MACSIS
33
Needed for billing; required by
Diagnostic Code P MACSIS
109
Partial Hospital Progress Note
110
Compliance Grid for Ohio SOQIC Forms
Pharmacologic/Nursing Progress Note (Long Version)
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Note: There are two versions of the Nursing Progress Note-- a long and short version. A grid was completed for only Ohio Medicaid as well as for
the long version of the form. Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-27-06 3793:2-1-06
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
All payers require that the client be
identified. Also, National
Accreditors all require sufficient
identifying information. Best
1 practice requires that the name or
client number or both of the
individual appear at the top of
every page in case the record
Client Name (First, MI, Last) Yes 06-N1 IM.6.20 becomes disassembled.
Use of an ID number would allow
2 the PHI to be de-identified as
Client No. 06-N1 defined by HIPAA.
If the only person present is the
Present at Session: List client, this does not need to be
3
Names of Persons Present; completed. This should be
Client present or no show reserved for family members and
checkbox others that attend.
4 IM.6.10
Client/Symptom Update (B)(3) 06-M, N IM.6.20 2.C.7 P
5 New Issue(s) Presented
Today (B)(3) 06-M, N IM.6.20 2.C.7
If the no notable change checkbox
is checked off regularly, the
medical necessity of the services
will be questioned- is the client
6 benefiting, is the service
necessary if no change is being
Relative changes in client's demonstrated, is the client
condition, checkboxes and unwilling or unable to participate
narrative; checkbox if no IM.6.10 causing no progress? ODADAS
change (B)(3) 06-M, N IM.6.20 2.C.7 P requires statement of progress.
7 Measurements
8 IM.6.10 May add to complexity of visit for
Vital Signs IM.6.20 E&M coding
111
Pharmacologic/Nursing Progress Note (Long Version)
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Note: There are two versions of the Nursing Progress Note-- a long and short version. A grid was completed for only Ohio Medicaid as well as for
the long version of the form. Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-27-06 3793:2-1-06
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
9 IM.6.10 May add to complexity of visit for
Height/Weight IM.6.20 E&M coding
CARF requires that AIMS be done
at beginning of treatment and
10
every three months thereafter.
Most payers want testing done as
AIMS Check 2.E.8.c medically necessary.
CARF requires that the progress
notes are able to readily identify
the goals and objectives that were
achieved or revised during the
11 session, as well as significant
events or changes the person's life
and specific services provided that
support the individual's service
plan. CARF's standard is typical of
the accreditors. Payers want
Goals/Objectives Addressed treatment interventions closely
from ISP 02(A) (A) 06-M IM.6.20 2.C.7 P related to goals and objectives.
Therapeutic interventions are the
tools that are used to produce
progress towards individualized
goals and objectives. Payers are
paying for therapeutic
interventions that are delivered by
12 individuals with the expertise to
use them effectively and to
customize them to the client's
individual profile and needs.
Progress notes that do not
Therapeutic Interventions describe an intervention are not
Provided 02(G)(6) (B)(2) 06-M IM.6.20 2.C.7 P billable.
112
Pharmacologic/Nursing Progress Note (Long Version)
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Note: There are two versions of the Nursing Progress Note-- a long and short version. A grid was completed for only Ohio Medicaid as well as for
the long version of the form. Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-27-06 3793:2-1-06
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
The payers expect that the
therapeutic interventions described
above will produce a response
from the client. This response may
be anywhere on the continuum
from negative to neutral to
positive. Auditors will look for a
description of the response and its
relationship to the progress of the
13 individual towards their goals and
objectives in all progress notes.
The auditors do not expect that
each intervention will result in
tangible progress but do expect
that the client's reaction or
response will be used to develop
continuing strategy. OAC 5101:3-
27-02 (G)(7) requires the
Response to individual's response to the
Intervention/Progress intervention be documented in the
Toward Goals/Objectives 02(G)(7) (B)(3) 06-M, N5 IM.6.20 2.C.7 s P progress note.
Issues referred to
14 Physician/APRN for
consideration
Signatures with credential of the
provider and date of the signature
are needed for billing. The auditor
will look to make sure that the
person providing the service has
the appropriate credentials.
15 Providers should be aware of
payer rules and should follow them
regarding signatures, including the
need for supervisory signatures on
some documents. The date should
be the date of the signature, not
the date of service unless the note
Nurse 02(A) & was written on the same day as
Signature/Credential/Date 02(G)(4) (B)(4) 06-N6 IM.6.10 2.C.7 the service.
113
Pharmacologic/Nursing Progress Note (Long Version)
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Note: There are two versions of the Nursing Progress Note-- a long and short version. A grid was completed for only Ohio Medicaid as well as for
the long version of the form. Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-27-06 3793:2-1-06
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
Please note: billing "incident to"
requires that the physician or other
supervising professional be on-site
16 and that all other rules of "incident
to" billing be followed. In addition,
the content of the group must meet
the definition of the service being
Medicare "Incident to" billed as described in CPT in order
Services Only for it to be Medicare eligible.
Medicare Services Only-
17 Name/Credentials of
Medicare Supervising Required only if service billed
Professional on Site "incident to"
Date of service is required on the
claim. Medicaid references the
18
DMH requirements for this
Date of Service 02(G)(1) (B)(1) 06-N2 documentation.
19 Staff ID No.
20 Needed for billing; required by
Location Code Yes MACSIS
21 Needed for billing; required by
Pcdr Code Yes MACSIS
22 Needed for billing; required by
Modifier (1-4) Yes MACSIS
23 Start Time 02(G)(2) 06-N3
24 Stop Time 02(G)(3) 06-N3
25 Total Time 02(G)(3) 06-N3 Needed for billing
26
Diagnostic Code Needed for billing
114
Compliance Grid for Ohio SOQIC Forms
Group Progress Note
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-27-06 3793:2-1-06
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
All payers require that the client be
identified. Also, National
Accreditors all require sufficient
identifying information. Best
1 practice requires that the name or
client number or both of the
individual appear at the top of
every page in case the record
Client Name (First, MI, Last) Yes 06-N1 IM.6.20 becomes disassembled.
Use of an ID number would allow
2 the PHI to be de-identified as
Client No. 06-N1 defined by HIPAA.
Type of Service:
3 CPST;
Counseling/Psychotherapy;
IOP; AoD Group Counseling;
Other; Client No Needed for billing to identify
Show/Cancelled Checkboxes 06-N4 service codes
4 Group Name IM.6.20 2.C.7 For convenience of the clinician
Each payer has regulations on
how many make a group so
important to keep in for billing.
5 ODADAS requires two or more
individuals so needed to confirm
group. ODADAS citation for group
Number in Group 08-O counseling is 3793:2-1-08(O).
6 No. of Staff 08-O
7 General Group Information-
Group Activity/Topic 02(G)(5) (B)(2) 06-N5 IM.6.20 2.C.7
115
Group Progress Note
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-27-06 3793:2-1-06
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
The payer is looking for evidence
that the client is able to participate
in the session and also that, given
the client's current condition, the
8 service is appropriate and clinically
indicated. For example, a client
who is actively hallucinating and
responding to voices may not
Individual Client Information- IM.6.10 benefit from or be able to
Functioning (B)(3) & 6.20 2.C.7 P participate in a therapy group.
If a client is experiencing stressors
or an extraordinary event, the
payer will for the provider's
assessment of how this should
effect today's service and the
9 strategy going forward including
the need to change the treatment
plan. Stressors and extraordinary
events may also explain situations
Stressors/Extraordinary in which the client is non-
Events or Checkbox for participatory, inactive or appears
None Reported IM.6.20 2.C.7 s to be relapsing.
10 New Issue(s) Presented
Today (B)(3) 06-M, N IM.6.20 2.C.7
CARF requires that the progress
notes are able to readily identify
the goals and objectives that were
achieved or revised during the
11 session, as well as significant
events or changes the person's life
and specific services provided that
support the individual's service
plan. CARF's standard is typical of
the accreditors. Payers want
Goal/Objective addressed treatment interventions closely
from ISP 02(A) (A) 06-M IM.6.20 2.C.7 P related to goals and objectives.
116
Group Progress Note
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-27-06 3793:2-1-06
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
Therapeutic interventions are the
tools that are used to produce
progress towards individualized
goals and objectives. Payers are
paying for therapeutic
interventions that are delivered by
12 individuals with the expertise to
use them effectively and to
customize them to the client's
individual profile and needs.
Progress notes that do not
Therapeutic Interventions RPM describe an intervention are not
Provided 02(G)(6) (B)(2) 06-M IM.6.20 7.02f 2.C.7 P billable.
The payers expect that the
therapeutic interventions described
above will produce a response
from the client. This response may
be anywhere on the continuum
from negative to neutral to
positive. Auditors will look for a
description of the response and its
relationship to the progress of the
13 individual towards their goals and
objectives in all progress notes.
The auditors do not expect that
each intervention will result in
tangible progress but do expect
that the client's reaction or
response will be used to develop
continuing strategy. OAC 5101:3-
27-02 (G)(7) requires the
Response to individual's response to the
Intervention/Progress RPM intervention be documented in the
Toward Goals/Objectives 02(G)(7) (B)(3) 06-M, N5 IM.6.20 7.02f 2.C.7 P s P progress note.
117
Group Progress Note
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-27-06 3793:2-1-06
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
Signatures with credential of the
provider and date of the signature
are needed for billing. The auditor
will look to make sure that the
person providing the service has
the appropriate credentials.
14 Providers should be aware of
payer rules and should follow them
regarding signatures, including the
need for supervisory signatures on
some documents. The date should
be the date of the signature, not
Provider the date of service unless the note
Signature/Credential/Date of 02(A) & RPM was written on the same day as
Signature 02(G)(4) (B)(4) 06-N6 7.04c 2.C.7 the service.
Co-provider
15 Signature/Credential/Date of 02(A) & RPM
Signature 02(G)(4) (B)(4) 06-N6 7.04c 2.C.7 See above
Supervisor
16 Signature/Credential/Date of 02(A) & RPM See above, may be needed for
Signature (if required) 02(G)(4) 06-E 7.04d 2.C.7 billing
If used by the provider
organization, the client's signature
17 Client Signature and Date of does provide evidence to payers
Signature (optional, if that the service actually happened
clinically appropriate) s as documented.
Please note: billing "incident to"
requires that the physician or other
supervising professional be on-site
18 and that all other rules of "incident
to" billing be followed. In addition,
the content of the group must meet
the definition of the service being
Medicare "Incident to" billed as described in CPT in order
Services Only for it to be Medicare eligible.
118
Group Progress Note
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-27-06 3793:2-1-06
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
Medicare Services Only-
19 Name/Credentials of
Medicare Supervising Required only if service billed
Professional on Site "incident to"
Date of service is required on the
claim. Medicaid references the
20
DMH requirements for this
Date of Service 02(G)(1) (B)(1) 06-N2 documentation.
21 Staff ID No.
22 Needed for billing; required by
Location Code Yes MACSIS
23 Needed for billing; required by
Prcdr Code Yes MACSIS
24 Needed for billing; required by
Modiier (1-4) Yes MACSIS
25 Start Time 02(G)(2) 06-N3
26 Stop Time 02(G)(3) 06-N3
27 Total Time 02(G)(3) 06-N3 Needed for billing
28
Diagnostic Code P Needed for billing
119
Compliance Grid for Ohio SOQIC Forms
Individual Progress Note
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-06 3793:2-1-06
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
All payers require that the client be
identified. Also, National
Accreditors all require sufficient
identifying information. Best
1 practice requires that the name or
client number or both of the
individual appear at the top of
every page in case the record
Client Name (First, MI, Last) Yes 06-N1 IM.6.20 becomes disassembled.
Use of an ID number would allow
2 the PHI to be de-identified as
Client No. 06-N1 defined by HIPAA.
Type of Service: Checkboxes
for
3 Counseling/Psychotherapy,
Crisis Intervention, Family
Counseling, Individual
Counseling, Case
Management 06-N4
If the only person present is the
Present at Session: List client, this does not need to be
4
Names of Persons Present; completed. This should be
Client present or no show reserved for family members and
checkbox others that attend.
May speak to need to see
Observed/Reported changes physician but not a primary source
5
in Medical Condition or of medical necessity for therapy
checkbox for None Reported (B)(3) 06-M IM.6.20 2.C.7 s services.
120
Individual Progress Note
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-06 3793:2-1-06
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
If the client is experiencing
stressors or an extraordinary
event, the payer will look for the
provider's assessment of how this
should effect today's service and
6 the strategy going forward
including the need to change the
treatment plan. Stressors and
extraordinary events may also
Stressors/Extraordinary explain situations in which the
Events or checkbox for None client in non-participatory, inactive
Reported. IM.6.20 2.C.7 P or appears to be relapsing.
New Issues(s) Presented
Today- none checkbox &
7
checkboxes: DA update
required; new information, no
DA update required (B)(3) 06-M, N IM.6.20 2.C.7
If the no significant change
checkbox is checked off regularly,
the medical necessity of the
services will be questioned- is the
8 Relative Changes in Client's client benefiting, is the service
Condition- (for face to face necessary if no change is being
visit) Checklist for mini- demonstrated, is the client
mental status. Checkbox for unwilling or unable to participate
No Significant Change From causing no progress? ODADAS
Last Visit. (B)(3) 06-M, N IM.6.20 2.C.7 requires statement of progress.
121
Individual Progress Note
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-06 3793:2-1-06
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
CARF requires that the progress
notes are able to readily identify
the goals and objectives that were
achieved or revised during the
9 session, as well as significant
events or changes the person's life
and specific services provided that
support the individual's service
plan. CARF's standard is typical of
the accreditors. Payers want
Goals/Objectives Addressed treatment interventions closely
from ISP 02(A) (A) 06-M IM.6.20 2.C.7 P related to goals and objectives.
Therapeutic interventions are the
tools that are used to produce
progress towards individualized
goals and objectives. Payers are
paying for therapeutic
interventions that are delivered by
10 individuals with the expertise to
use them effectively and to
customize them to the client's
individual profile and needs.
Progress notes that do not
Therapeutic Interventions RPM describe an intervention are not
Provided 02(G)(6) (B)(2) 06-M IM.6.20 7.02f 2.C.7 P billable.
122
Individual Progress Note
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-06 3793:2-1-06
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
The payers expect that the
therapeutic interventions described
above will produce a response
from the client. This response may
be anywhere on the continuum
from negative to neutral to
positive. Auditors will look for a
description of the response and its
relationship to the progress of the
11 individual towards their goals and
objectives in all progress notes.
The auditors do not expect that
each intervention will result in
tangible progress but do expect
that the client's reaction or
response will be used to develop
continuing strategy. OAC 5101:3-
27-02 (G)(7) requires the
Response to individual's response to the
Intervention/Progress RPM intervention be documented in the
Towards Goals/Objectives 02(G)(7) (B)(3) 06-M, N5 IM.6.20 7.02f 2.C.7 s P progress note.
ODADAS wants narrative to
include a justification for continuing
treatment. This may be the
appropriate place to record this.
12 The plan should reflect any
changes in strategy that resulted
from the session or the cumulative
progress or lack of progress of the
client towards goals and
Additional Information/Plan 2.C.7 P objectives.
13 Date/Time Next Appointment
Client's assessment of their
14 Client's Rating of Their benefit/progress in treatment;
Progress- fill in the rating indirectly speaks to client's ability
number s P and willingness to participate.
123
Individual Progress Note
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-06 3793:2-1-06
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
If used by the provider
organization, the client's signature
15 Client Signature and Date of does provide evidence to payers
Signature (optional if that the service actually happened
clinically appropriate) s as documented.
Signatures with credential of the
provider and date of the signature
are needed for billing. The auditor
will look to make sure that the
person providing the service has
the appropriate credentials.
16 Providers should be aware of
payer rules and should follow them
regarding signatures, including the
need for supervisory signatures on
some documents. The date should
be the date of the signature, not
Provider the date of service unless the note
Signature/Credential/Date of 02(A) & RPM was written on the same day as
Signature 02(G)(4) (B)(4) 06-N6 7.04c 2.C.7 the service.
17 Supervisor Signature/Date of 02(A) & RPM See above, may be needed for
Signature (if required) 02(G)(4) 06-E 7.04d 2.C.7 billing.
Please note: billing "incident to"
requires that the physician or other
supervising professional be on-site
18 and that all other rules of "incident
to" billing be followed. In addition,
the content of the group must meet
Medicare Only- Medicare the definition of the service being
Services Only: This service billed as described in CPT in order
is provided in "incident to" for it to be Medicare eligible.
Medicare Only-
Name/Credentials of
19
Supervising Professional on Required only if service will be
Site billed "incident to"
Date of service is required on the
claim. Medicaid references the
20
DMH requirements for this
Date of Service 02(G)(1) (B)(1) 06-N2 documentation.
124
Individual Progress Note
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-06 3793:2-1-06
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
21 Staff ID No.
22 Needed for billing; required by
Location Code Yes MACSIS
23 Needed for billing; required by
Prcdr Code Yes MACSIS
24 Needed for billing; required by
Modifier (1-4) Yes MACSIS
25 Start Time 02(G)(2) 06-N3
26 Stop Time 02(G)(3) 06-N3
27 Total Time 02(G)(3) 06-N3 Needed for billing
28 Diagnostic Code P Needed for billing
125
Compliance Grid for Ohio SOQIC Forms
Community Psychiatric Supportive Treatment Progress Note (Short Version)
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-06 See Note
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
***Note: ODADAS does not have
regulations for Community
Psychiatric Supportive Treatment
service. Therefore, ODADAS
regulations are not addressed in
1 the grid for this form. All payers
require that the client be identified.
Also, National Accreditors all
require sufficient identifying
information. Best practice requires
that the name or client number or
both of the individual appear at the
top of every page in case the
Client Name (First, MI, Last) Yes IM.6.20 record becomes disassembled.
Use of an ID number would allow
2 the PHI to be de-identified as
Client No. defined by HIPAA.
The activity offered must be one
that is ordered in the treatment
3 plan as well as one that is listed as
an allowable service under the
Activity Offered- checkboxes 5122-29-17 definition of community support
for type of activity 02(G)(5) (B) 2.C.7 s services in the regulations.
If the only person present is the
Present at Session: List client, this does not need to be
4
Names of Persons Present; completed. This should be
Client present or no show reserved for family members and
checkbox others that attend.
Observed/Reported
Changes in Medical
5 Condition and Actions
Taken; checkbox for None
Reported
126
Community Psychiatric Supportive Treatment Progress Note (Short Version)
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-06 See Note
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
6 Functioning- IM.6.10
observed/reported (B)(3) & 6.20 2.C.7
7 New Issue(s) Presented
Today (B)(3) IM.6.20 2.C.7
CARF requires that the progress
notes are able to readily identify
the goals and objectives that were
achieved or revised during the
8 session, as well as significant
events or changes the person's life
and specific services provided that
support the individual's service
plan. CARF's standard is typical of
the accreditors. Payers want
Goals/Objective Addressed treatment interventions closely
from ISP 02(A) (A) IM.6.20 2.C.7 P s s related to goals and objectives.
Therapeutic interventions are the
tools that are used to produce
progress towards individualized
goals and objectives. Payers are
paying for therapeutic
interventions that are delivered by
9 individuals with the expertise to
use them effectively and to
customize them to the client's
individual profile and needs.
Progress notes that do not
Therapeutic Interventions RPM describe an intervention are not
Provided 02(G)(6) (B)(2) IM.6.20 7.02f 2.C.7 P billable.
127
Community Psychiatric Supportive Treatment Progress Note (Short Version)
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-06 See Note
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
The payers expect that the
therapeutic interventions described
above will produce a response
from the client. This response may
be anywhere on the continuum
from negative to neutral to
positive. Auditors will look for a
description of the response and its
relationship to the progress of the
10 individual towards their goals and
objectives in all progress notes.
The auditors do not expect that
each intervention will result in
tangible progress but do expect
that the client's reaction or
response will be used to develop
continuing strategy. OAC 5101:3-
27-02 (G)(7) requires the
Response to individual's response to the
Intervention/Progress RPM intervention be documented in the
Towards Goals/Objectives 02(G)(7) (B)(3) IM.6.20 7.02f 2.C.7 P s P progress note.
Signatures with credential of the
provider and date of the signature
are needed for billing. The auditor
will look to make sure that the
person providing the service has
the appropriate credentials.
11 Providers should be aware of
payer rules and should follow them
regarding signatures, including the
need for supervisory signatures on
some documents. The date should
be the date of the signature, not
the date of service unless the note
Provider 02(A) & RPM was written on the same day as
Signature/Credential/Date 02(G)(4) (B)(4) 7.02c 2.C.7 the service.
12 Provider No. (optional)
128
Community Psychiatric Supportive Treatment Progress Note (Short Version)
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
5101:3-27 5122-29-06 See Note
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
If used by the provider
organization, the client's signature
13 Client Signature/Date of does provide evidence to payers
Signature (optional, if that the service actually happened
clinically appropriate) s as documented.
Supervisor
14 Signature/Credential/Date of 02(A) & RPM Needed for billing; required by
Signature (if required) 02(G)(4) 7.02d 2.C.7 MACSIS
Date of service is required on the
claim. Medicaid references the
15
DMH requirements for this
Date of Service 02(G)(1) (B)(1) documentation.
16 Staff ID No.
17 Needed for billing; required by
Location Code Yes MACSIS
18 Needed for billing; required by
Prcdr Code Yes MACSIS
19 Modifier (1-4) Yes
20 Start Time 02(G)(2)
21 Stop Time 02(G)(3)
22 Needed for billing; required by
Total Time 02(G)(3) MACSIS
23
Needed for billing; required by
Diagnostic Code P MACSIS
129
Compliance Grid for Ohio SOQIC Forms
Transfer/Discharge Summary
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
3793:2-1-
5101:3-27 5122-27-07
06
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
All payers require that the client be
identified. Also, National
Accreditors all require sufficient
identifying information. Best
1 practice requires that the name or
client number or both of the
individual appear at the top of
every page in case the record
Client Name (First, MI, Last) 06-P-1 IM.6.20 becomes disassembled.
Use of an ID number would allow
2 the PHI to be de-identified as
Client No. 06-P-1 defined by HIPAA.
Checkboxes to identify use of
form: Discharge from Agency,
3 Service and/or Program
Termination or Transfer. If
transfer, space to list program
client is being transferred
from and to.
4 Admission Date (B)(1) 06-P-2 2.D.9.a
5 Last Contact (B)(2)
6 Transfer/Termination/
Discharge Date 06-P-3 2.D.9.k
Presenting Problem(s)
(indicate presenting problem
7
at admission and any
additional problems
addressed during treatment.) 2.D.9.c
130
Transfer/Discharge Summary
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
3793:2-1-
5101:3-27 5122-27-07
06
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
Reason for
Transfer/Termination or
8
Discharge with Referral- This information will enhance
Checkboxes and Narrative IM.6.10 RPM 2.D.9.f, continuity of care efforts for the
Sections to list referrals. (B)(4) 06-P-8 & 6.20 7.02j h,i client.
Diagnosis: At Admission,
9 Checkboxes (DSM or ICD)- This information will enhance
Axis I - V, DSM or ICD Code, IM.6.10 continuity of care efforts for the
Description 06-P-4 & 6.20 P client.
Diagnosis: At time of
Transfer/Discharge, Check
10
Boxes (DSM or ICD) - Axis I -
V, DSM or ICD Code, IM.6.10
Description 06-P-4 & 6.20
Client Outcomes Information-
11 Checkboxes for adult,
child/adolescent, other
12 Outcomes- For Adults Only-
Scores
Outcomes- For
13 Children/Adolescents Only-
Scores
This information will enhance
continuity of care efforts for the
14 Goals addressed- Progress client. It also justifies cost of care
made as written in ISP- check IM.6.10 and speaks directly to client
boxes (B)(3) 06-P-7 & 6.20 2.D.9.d P P benefit.
Overall Progress in
15 Treatment- checkboxes to IM.6.10
rate improvement (B)(3) 06-P-7 & 6.20 2.D.9.e
16 Comments (include progress,
strengths, current status) IM.6.10 2.D.9.e,g
AoD Only Adult Level of
19 Care- checkboxes for ODADAS requires completion of
identifying level of care 06-P-6 Level of Care worksheet.
131
Transfer/Discharge Summary
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
3793:2-1-
5101:3-27 5122-27-07
06
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
AoD Only Youth Level of
20 Care- checkboxes for ODADAS requires completion of
identifying level of care 06-P-6 Level of Care worksheet.
Services Provided- check This information will enhance
21 types of services provided continuity of care efforts for the
during treatment 06-P-6 IM.6.10 2.D.9.b P client.
Current Medications
(Prescription/OTC/Herbal) at
22 Time of Transfer/Discharge;
checkboxes to indicate:
Prescribed by this agency or
As reported by client; indicate This information will enhance
Dosage, Route, Frequency, continuity of care efforts for the
Prescribing Physician (B)(5) IM.6.20 2.D.9.j P client.
Goal 8
Medication reconciliation National
completed, client given list of Patient
all medications (Joint Safety
Commission only) Goals
23 Client's response to This information will enhance
treatment and IM.6.10 continuity of care efforts for the
transfer/termination/discharge (B)(3) 06-P-7 & 6.20 2.D.9.e P s s client.
This information will enhance
24 Recommendations/referrals IM.6.10 continuity of care efforts for the
for additional treatment (B)(4) 06-P-8 & 6.20 2.D.9.i P client.
Aftercare Options (symptoms
25 to watch for, additional RPM
services) 7.02j 2.D.9.e
Copy of Transfer/Discharge
26 Summary- checkboxes if
given or mailed to client
132
Transfer/Discharge Summary
Please note the issues of medical
necessity/participation and benefit
MCD/CARE Requirements are similar for both Federal and
Ohio Medicaid as well as for
Medicare
Ohio Administrative Code Rule Accreditation Issues This helps make the case for:
3793:2-1-
5101:3-27 5122-27-07
06
No.
Medical Client Client
on Element MEDICAID ODMH ODADAS TJC COA CARF Comments
Necessity Participation Benefit
Form
Signatures with credential of the
provider and date of the signature
are needed for billing. The auditor
will look to make sure that the
person providing the service has
the appropriate credentials.
27 Providers should be aware of
payer rules and should follow them
regarding signatures, including the
need for supervisory signatures on
some documents. The date should
be the date of the signature, not
the date of service unless the note
Provider RPM was written on the same day as
Signature/Credential/Date (B)(7) 06-P-9 IM.6.10 7.04c the service.
Supervisor
28 Signature/Credential/Date of RPM Needed for billing; required by
Signature (if required) 7.04d MACSIS
133
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