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Medicaid Self Assessment - OASAS

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Medicaid Self Assessment - OASAS Powered By Docstoc
					                                                                                         ASSESSMENT INFORMATION


                                                                       ___________________________________________________
                                                                                            PROVIDER NAME
    DIVISION OF QUALITY ASSURANCE AND PERFORMANCE
                      IMPROVEMENT
            BUREAU OF STANDARDS COMPLIANCE                             Service Type:                                    Check One


          MEDICAID BILLING SELF-ASSESSMENT TOOL                        Part 822 Chemical Dependence Outpatient Clinic

(Applicable to Part 822 Medically Supervised Outpatient Services
             and Outpatient Rehabilitation Services)                   Part 822 Chemical Dependence Outpatient Rehab

                                                                       Former Part 823 Outpatient CD for Youth

                        PART I
                BACKGROUND/INSTRUCTIONS

                                                                       ________________________      ________________________
                           PART II                                         PROVIDER NUMBER                  PRU NUMBER
                      PATIENT RECORDS


                                                                       ___________________________________________________
                                                                                           REVIEWER'S NAME



                                                                       ___________________________________________________
                                                                                                 TITLE




                                                               7/13/2011
                                                 MEDICAID SELF-ASSESSMENT BACKGROUND AND INSTRUCTIONS
                                                            BACKGROUND AND INSTRUCTIONS
PURPOSE:                                                                           NOTES:

With the recent changes to Medicaid billing rules and codes; along with the        To best utilize the Medicaid Self-Assessment Tool the following should be
changes to the Part 822 Outpatient Services Regulations; the Medicaid Self-        considered:
Assessment Tool has been updated to:
                                                                                           The tool should be completed by someone who is savvy in both the
        Assist Providers in assessing compliance with regulations and new                  regulations, billing, and overall program operations;
         APG Billing;
        Identify strengths and weaknesses in case record documentation;                   The Self-Assessment Tool is designed to identify potential risk areas
         including efficacy of policy and procedures; and                                   in current written documentation, as such the assessment should not
        Improve case record procedures as necessary.                                       be used to correct past mistakes in the case record, but to focus on
                                                                                            eliminating or reducing the same risk in the future;

                                                                                           Based on past history and current knowledge particular focus should
To accomplish this purpose OASAS Technical Assistance developed the                         be placed on areas of non-compliance as follows:
question items based on the following:                                                           Accurate and timely dates and signatures as required,
                                                                                                    particularly in the area of comprehensive treatment/recovery
        Past history of quality indicators from OASAS Recertification reviews;                     plans;
        Past history of provider reported OMIG disallowances; and                               Service Durations;
        Present knowledge of APG Billing and the new 822 Regulations.                           Service Billing Limitations;
                                                                                                 Documentation not in case records;
**Please note that past history does not necessarily reflect present day
positive results.                                                                          Self-Assessments are intended to simulate in part, Medicaid and
                                                                                            OASAS audits and are only useful if uncovered deficiencies in case
                                                                                            record documentation procedures are timely and effectively
FORMAT:                                                                                     addressed.

The Self-Assessment Tool has been divided into sections that follow the
typical services offered to a patient as the go through the treatment process.     RESOURCES:
Other than questions that ask for dates, i.e. date of admission, comprehensive
evaluation, etc.; the questions solicit “yes,” “no,” or “na” answers. Questions    If you are concerned regarding the results of the Medicaid Self-Assessment
are scored based on the answers. Please be sure to fill in all boxes where         and would like to get further guidance and assistance please contact the
appropriate. Blank boxes and "NA's" will be scored as zeroes. At the end of        OASAS Technical Assistance Unit by email at:
each section there is a score calculated that reflects the “non-compliance”
percentage of that particular section. There is also a final scoring page at the                        TechnicalAssist@oasas.state.ny.us
end of the assessment tool that gives a summary of all sections and their
levels of “non-compliance.”                                                        Finally, information related to APGS generally, including the updated Part 822
                                                                                   regulation and an APG clinical and billing manual may be found at:

                                                                                              http://www.oasas.state.ny.us/admin/hcf/APG/Index.cfm

         **Please note that completion of the Medicaid Billing Self Assessment form is voluntary; neither
         guaranteeing immunity against Medicaid audit disallowances nor superseding OASAS Regulatory
         requirements or Federal Medicaid billing requirements.**
                                           MEDICAID SELF-ASSESSMENT BACKGROUND AND INSTRUCTIONS
                                                                SAMPLE SIZE
Since in the past the billing options were very limited, a single billing date was used for the sample unit. Under APGs programs may bill
Medicaid for multiple services on a single visit date and billed servies must adhere to certain billing limitation that are either date or
episode specific. As such, to ensure the assessment is ensuring a comprehensive view of billing practices, the updated Medicaid Self-
Assessment Tool is requiring that the entire patient case record be used as the sample unit. With the unit of measure changes the
suggested sample sizes are changing as well, and are consistent with sample selection practices used in the recertification review
process.
               For providers with less than 300 patients we are suggesting a sample size of a minimum 10 patient case records;

               For providers with over 300 patients we are suggesting a minimum of 20 patient case records.

 **Please choose Patient Case Records for Patients who have been in treatment at least six months; this allows for a sample that covers
a more complete range of services.
Patient Case Record Information: Fill in the information for each Patient Case Record used in the review process. Reminder the assessment should
be based on a case record, and not just a single date of service. This will help ensure that the assessment is providing a comprehensive view of
documentation and coding practices.
 Record     Medicaid Recipient ID Number      Patient ID Number                  Record    Medicaid Recipient ID Number      Patient ID Number
    1                                                                              11
    2                                                                              12
    3                                                                              13
    4                                                                              14
    5                                                                              15
    6                                                                              16
    7                                                                              17
    8                                                                              18
    9                                                                              19
    10                                                                             20
OASAS MEDICAID SELF ASSESSMENT TOOL CASE RECORDS
                          MEDICAID BILLING SELF-ASSESSMENT WORKSHEET INSTRUCTIONS - For Visit Dates After July 1, 2011
   Using the selected Patient Record(s) and corresponding Medicaid Remittance statement(s), complete the following information on the Self-Assessment
                                                                          Worksheet.
 1. SCREENING:                      Enter "Y" for Yes or "N" for No as indicated, otherwise enter information as directed.

 PATIENT CASE #                                                     1   2     3       4        5       6        7       8        9       10        Total
 1. Was a billable Screening service provided?                                                                                                      # of
                                                                                                                                                  Cases 0
 2. Was the appropriate billing code used for the Screening
 service (H0049)?                                                                                                                                    0
 3. For the Screening service provided is there documentation
 that indicates that the minimum 15 minute time requirement
 was met for the service provided? [(822-3.1(h)(13)]                                                                                                 0
 4. Did a clinical staff member conduct the face-to-face
 Screening Service as evidenced by their signature on the
 documentation? [(822-2.1(ac)][(822-2.5(a)(1)]                                                                                                       0
 5. For the selected patient record did program bill for only one
 screen per episode of care? [(822-3.1(h)(13)]                                                                                                       0
                                                       TOTALS:      0   0     0       0        0       0        0       0        0        0          0
                                                                                                               Percentage Out of Compliance:        0%




7/13/2011                                                                                                                                      Page 4 of 37
OASAS MEDICAID SELF ASSESSMENT TOOL CASE RECORDS
 2. BRIEF INTERVENTION:
 PATIENT CASE #                                                     1   2   3   4   5   6   7        8        9       10        Total
 1. Were billable Brief Intervention Service(s) Provided?                                                                        # of
                                                                                                                               Cases 0
 2. Was the appropriate billing code used for all Brief
 Intervention service(s) provided (H0050)?
                                                                                                                                  0
 3. For the selected patient record did the program limit total
 billed pre-admission Brief Intervention claims to no more than
 three? [(822-3.1(h)(2)]                                                                                                          0
 4. For each billable Brief Intervention service is there
 documentation that indicates that the 15 minute minimum
 time requirement was met for the service(s) provided? [(822-
 3.1(h)(2)]                                                                                                                       0
 5. For the selected patient record did the program limit billed
 Brief Intervention service to one service per patient per visit
 date? [(822-3.1(h)(2)]                                                                                                           0
 6. Did a clinical staff member conduct the face-to-face Brief
 Intervention service(s) as evidenced by their signature on the
 documentation? [(822-2.1(b)][(822-2.5(a)(1)]                                                                                     0
                                                          TOTALS:   0   0   0   0   0   0   0        0        0        0          0
                                                                                            Percentage Out of Compliance:        0%




7/13/2011                                                                                                                   Page 5 of 37
OASAS MEDICAID SELF ASSESSMENT TOOL CASE RECORDS
 3. PRE-ADMISSION ASSESSMENT :
 PATIENT CASE #                                                   1   2   3   4   5   6   7        8        9       10        Total
 1. Were billable Pre-Admission Assessment services                                                                            # of
 provided?                                                                                                                   Cases 0
 2. Were the appropriate billing codes used for all Pre-
 Admisson Assessment service(s) ?
 · Brief (15 minutes)(T1023)
 · Normative (30 minutes)(H0001)
 · Extended (75 minutes)(H0002 or CPT 90801*)
 * For those instances where a patient is dually enrolled in
 Medicaid/Medicare and the service and practitioner are
 reimbursable by Medicare the program may bill using a
 CPT code that corresponds to the service delivered AND
 the associated APG service category and weight.
                                                                                                                                0
 3. Were there no more than three pre-admission Assessment
 services billed for the patient. [(822-3.1(h)(1)]                                                                              0
 4.Did the program deliver and bill for only one Extended
 Assessment? [(822-3.1(h)(1)]                                                                                                   0
 5. For the selected patient record is there documentation that
 indicates minimum time requirements for all billable Pre-
 Admisson Assessment service(s) provided were met as
 follows:
 · Brief (15 minutes)
 · Normative (30 minutes)
 · Extended (75 minutes) [(822-3.1(h)(1)(i-iii)]                                                                                0
 6. Did program limit Pre-Admisson Assessment service(s)
 provided and billed to one per patient visit date? [(822-
 3.1(h)(1)]                                                                                                                     0
 7. Did a clinical staff member conduct the face-to-face
 Assessment service(s) as evidenced by their signature on the
 documentation? [(822-2.1(a)][(822-2.5(a)(1)]                                                                                   0
 8. Do the patient case records contain the name of the
 authorized QHP who made the admission decision as
 documented by their signature and date? [822-4.3(e)]                                                                           0
                                                        TOTALS:   0   0   0   0   0   0   0        0        0        0          0
                                                                                          Percentage Out of Compliance:        0%




7/13/2011                                                                                                                 Page 6 of 37
OASAS MEDICAID SELF ASSESSMENT TOOL CASE RECORDS
                              Enter the Admission Date
 4. COMPREHENSIVE EVALUATION:
 PATIENT CASE #                                                     1   2   3   4   5   6   7        8        9       10        Total
                                                                                                                                 # of
 1. Is there a Comprehensive Evaluation in the Case Record?                                                                    Cases 0

  Enter the Date of the Comprehensive Evaluation

 2. Are comprehensive evaluations completed by staff within
 45 days of admission? [822-4.4(a), (e)]                                                                                          0
 3. Do the evaluations include the dated signature of the
 Qualified Health Professional responsible for the evaluation
 and the person responsible for completing it? [822-4.4(c)] [822-
 4.4(a), (e)]                                                                                                                     0
                                                       TOTALS:      0   0   0   0   0   0   0        0        0        0          0
                                                                                            Percentage Out of Compliance:        0%




7/13/2011                                                                                                                   Page 7 of 37
OASAS MEDICAID SELF ASSESSMENT TOOL CASE RECORDS
 5. COMPREHENSIVE TREATMENT/RECOVERY PLANNING:
 PATIENT CASE #                                                  1   2   3   4   5   6   7        8        9       10        Total
 1. Is there a Comprehensive Treatment/Recovery Plan in the                                                                   # of
 case record?                                                                                                               Cases 0

 Date of the Comprehensive Treatment/Recovery Plan

 2. Are the comprehensive treatment/recovery plans approved
 within 45 days of admission (determined by latest dated
 signature of MDT)? [822-4.5(a)]                                                                                               0
 3. Are the comprehensive treatment/recovery plans reviewed
 and agreed upon in a case conference by a multidisciplinary
 team (MDT), and be signed and dated by all MDT members at
 or sometime following the case conference? [822-4.5(a), 822-
 4.5(c)(9)]                                                                                                                    0
 4. Are the comprehensive treatment/recovery plans approved
 signed and dated by the Medical Director or other physician
 employed by the outpatient program within 10 days of review
 and approval by the MDT? [822-4.5(c)(10)] (Note if the
 physician is a member and signatory of the MDT this
 regulatory requirement is satisfied)                                                                                          0
 5. Are the treatment plans signed by the responsible clinical
 staff member (primary counselor)? [822-4.5(c)(6, 10)]
                                                                                                                               0
 6. Is the entire treatment/recovery plan, once established,
 thoroughly reviewed and revised at least every 90 calendar
 days for the first year and at least every 180 calendar days
 thereafter as evidenced by the the dated signature of a
 member of the multi-disciplinary team; [822-4.5(g)]                                                                           0
                                                      TOTALS:    0   0   0   0   0   0   0        0        0        0          0
                                                                                         Percentage Out of Compliance:        0%




7/13/2011                                                                                                                Page 8 of 37
OASAS MEDICAID SELF ASSESSMENT TOOL CASE RECORDS
 6. MEDICATION MANAGEMENT COMPLEX:
 PATIENT CASE #                                                      1   2   3   4   5   6   7        8        9       10        Total
 1. Were billable Medication Management Complex service(s)                                                                        # of
 provided?                                                                                                                      Cases 0
 2. Was the appropriate billing code used for all Medication
 Management Complex service(s) provided (90862)?                                                                                   0
 3. For all billable Medication Management Complex
 service(s) is there documentation that indicates that the 15
 minute minimum time requirement was met for the
 service(s) provided? [822-3.1(h)(10)(ii)]                                                                                         0
 4. Did program limit all Medication Management Complex
 service(s) provision and billing to one service per patient visit
 date? [822-3.1(h)(10)]                                                                                                            0
 5. Did a Prescribing Professional conduct the face-to-face
 Medication Mgt. Complex Service as evidenced by their
 signature on the documentation? [(822-2.1(t)][(822-
 2.5(a)(1)]                                                                                                                        0
                                                        TOTALS:      0   0   0   0   0   0   0        0        0        0          0
                                                                                             Percentage Out of Compliance:        0%
 7. ADDICTION MEDICATION INDUCTION (AMI):
 PATIENT CASE #                                                      1   2   3   4   5   6   7        8        9       10        Total
 1. Were billable Addiction Medication Induction services(s)                                                                      # of
 provided?                                                                                                                      Cases 0
 2. Was the appropriate billing code used for all Addiction
 Medication Induction service(s) (H0014)?                                                                                          0
 3. For all billable Addiction Medication Induction services(s)
 is there documentation that indicates that the 30 minute
 minimum time requirement was met for the service(s)
 provided?                                                                                                                         0
 4. Did the program limit Addiction Medication Induction
 services(s) provision and billing to one service per patient
 visit date?                                                                                                                       0
  [822-3.1(h)(10)(ii)]
 5. Did a Prescribing Professional conduct the Addiction
 Medication Induction service(s) as evidenced by their
 signature on the documentation? [(822-2.1(t)][(822-
 2.5(a)(1)]                                                                                                                        0
                                                       TOTALS:       0   0   0   0   0   0   0        0        0        0          0
                                                                                             Percentage Out of Compliance:        0%



7/13/2011                                                                                                                    Page 9 of 37
OASAS MEDICAID SELF ASSESSMENT TOOL CASE RECORDS
 8. MEDICATION MANAGEMENT ROUTINE:
 PATIENT CASE #                                                  1   2   3   4   5   6   7        8        9       10     Total
 1. Were billable Medication Management Routine service(s)                                                                 # of
 provided?                                                                                                               Cases 0
 2. Was the appropriate billing code used for all of the
 Medication Management Routine service(s) provided
 (M0064))?                                                                                                                  0
 3. For all billed Medication Management Routine service(s)
 is there documentation that indicates that the 10 minute
 minimum time requirement was met for the service(s)
 provided? [822-3.1(h)(10)(i)]                                                                                              0
 4. Did program limit Medication Management Routine service
 provision and billing to one service per patient visit date?
 [822-3.1(h)(10)(i-ii)]                                                                                                     0
 5. Did a Prescribing Professional conduct all of the face-to-
 face Medication Management Routine service(s) as
 evidenced by their signature on the documentation? [(822-
 2.1(ab)][(822-2.5(a)(1)]                                                                                                   0
                                                     TOTALS:     0   0   0   0   0   0   0        0        0        0       0
                                                                                         Percentage Out of Compliance:     0%




7/13/2011                                                                                                            Page 10 of 37
OASAS MEDICAID SELF ASSESSMENT TOOL CASE RECORDS
 9. MEDICATION ADMINISTRATION AND OBSERVATION:
 PATIENT CASE #                                                1   2   3   4   5   6   7        8        9       10     Total
 1. Were billable Medication Administrative and Observation                                                              # of
 service(s) provided?                                                                                                  Cases 0
 2. Were the appropriate billing code(s) used for the
 Medication Administrative and Observation service(s) (H0020
 Methadone) (H0033 Oral Medication)?                                                                                      0
 3. Was there no more than one Medication Administrative
 and Observation service provided and billed per patient
 service day? [822-3.1(h)(9)]
                                                                                                                          0
 4. Did a medical staff member conduct all the face-to-face
 Medication Administrative and Observation service(s) as
 evidenced by their signature on the documentation?
 [(822-2.1(s)][(822-2.5(a)(1)]                                                                                            0
                                                     TOTALS:   0   0   0   0   0   0   0        0        0        0       0
                                                                                       Percentage Out of Compliance:     0%




7/13/2011                                                                                                          Page 11 of 37
OASAS MEDICAID SELF ASSESSMENT TOOL CASE RECORDS
 10. COLLATERAL CONTACT:
 PATIENT CASE #                                                    1   2   3   4   5   6   7        8        9       10     Total
 1. Were billable Collateral Contact Service(s) Provided?                                                                    # of
                                                                                                                           Cases 0
 2. Were the appropriate billing codes used for the Collateral
 Contact service(s) (T1006 or CPT 90846*)?
 * For those instances where a patient is dually enrolled in
 Medicaid/Medicare and the service and practitioner are
 reimbursable by Medicare the program may bill using a
 CPT code that corresponds to the service delivered AND
 the associated APG service category and weight.
                                                                                                                              0
 3. For the selected patient record did the program limit billed
 Collateral Contact services to no more than five; within an
 episode of care? [822-3.1(h)(4)]                                                                                             0
 4. For each billable Collateral Contact service is there
 documentation that indicates the 30 minute minimum time
 requirement was met? [822-3.1(h)(4)]                                                                                         0
 5. For the selected patient record did the program limit billed
 Collateral Contact service to one per patient visit date?
 [822-3.1(h)(4)]                                                                                                              0
 6. Did a clinical staff member conduct the face-to-face
 Collateral Contact service(s) as evidenced by their signature
 on the documentation? [(822-2.1(h)][(822-2.5(a)(1)]                                                                          0
                                                        TOTALS:    0   0   0   0   0   0   0        0        0        0       0
                                                                                           Percentage Out of Compliance:     0%




7/13/2011                                                                                                              Page 12 of 37
OASAS MEDICAID SELF ASSESSMENT TOOL CASE RECORDS

 11. OUTPATIENT REHABILITATION: (Only programs that are CERTIFIED by OASAS as Outpatient Rehabilitation may bill for such service)
 PATIENT CASE #                                                      1   2   3      4       5        6       7        8        9       10     Total
 1. Were billable Outpatient Rehabilitation Service(s)                                                                                         # of
 Provided?                                                                                                                                   Cases 0
 2. Were the appropriate billing codes used for the Outpatient
 Rehabilitation service(s)?
 · Partial: Day 2-4 hours (H2001) OR
 · Full: four hour and above (H2036)                                                                                                            0
 3. For each billable Outpatient Rehabilitation service is there
 documentation that indicates the minimum time requirement
 was met? [822-3.1(h)(11)(i-ii)]
 · Partial Day - 2-4 hours OR
 · Full Day - 4+ hours                                                                                                                          0
 4. Did program limit billed Outpatient Rehabilitation services to
 one per patient visit day? [822-3.1(h)(11)]                                                                                                    0
 5. With the exception of medication management, complex
 care, peer services and collateral contacts; did the program
 exclude billing for any other services billed for on the same
 date(s) as the Outpatient Rehabilitation service? [822-
 3.1(h)(11)]                                                                                                                                    0
                                                         TOTALS:     0   0   0      0       0        0       0        0        0        0       0
                                                                                                             Percentage Out of Compliance:     0%




7/13/2011                                                                                                                                Page 13 of 37
OASAS MEDICAID SELF ASSESSMENT TOOL CASE RECORDS
 12. INTENSIVE OUTPATIENT SERVICES (IOS): (NOTE: Does not require separate OASAS Certification)
 PATIENT CASE #                                                     1   2   3    4       5        6   7        8        9       10     Total
 1. Were billable Intensive Outpatient Service(s) Provided?                                                                             # of
                                                                                                                                      Cases 0
 2. Was the appropriate billing codes used for the Intensive
 Outpatient service(s)? (S9480)                                                                                                          0
 3. For each billable Intensive Outpatient service is there
 documentation that indicates the minimum time requirement
 was met? [822-3.1(h)(8)]
 · 9 hours of treatment sessions per week.
 · 3 hours per day.
                                                                                                                                         0
 4. For the selected patient record did the program limit patient
 participation in IOS to no more than six weeks of Intensive
 Outpatient services provided unless there was clinical
 justification for additional time? [822-3.1(h)(8)]                                                                                      0
                                                       TOTALS:      0   0   0    0       0        0   0        0        0        0       0
                                                                                                      Percentage Out of Compliance:     0%




7/13/2011                                                                                                                         Page 14 of 37
OASAS MEDICAID SELF ASSESSMENT TOOL CASE RECORDS
 13. INDIVIDUAL COUNSELING:
 PATIENT CASE #                                                     1   2   3   4   5   6   7        8        9       10     Total
 1. Was a billable Individual Counseling Service Provided?                                                                    # of
                                                                                                                            Cases 0
 2. Was the appropriate billing codes used for the Individual
 Counseling service(s) ?
 · Brief 25 minutes (G0396) or CPT 90804*
 · Normative 45 minutes (G0397) or CPT 90806*

 * For those instances where a patient is dually enrolled in
 Medicaid/Medicare and the service and practitioner are
 reimbursable by Medicare the program may bill using a
 CPT code that corresponds to the service delivered AND
 the associated APG service category and weight.
                                                                                                                               0
 3. For each billed Individual Counseling service is there
 documentation that indicates minimum time requirement were
 met for the service(s) provided as follows:
 · Brief (25 minutes)
 · Normative (45 minutes) [(822-3.1(h)(7)]                                                                                     0
 4. For the selected patient record did the program limit billing
 to one Individual Counseling service per patient visit ?
 [(822-3.1(h)(7)]                                                                                                              0
 5. Did a clinical staff member conduct the face-to-face
 Individual Counseling service(s) as evidenced by their
 signature on the documentation? [(822-2.1(m)][(822-                                                                           0
 2.5(a)(1)] for medication management, complex care, peer
 6. Except
 services and collateral contacts did the program limit billed
 services to no more than two for the visit date(s) of the
 Individual Counseling service?                                                                                                0
                                                        TOTALS:     0   0   0   0   0   0   0        0        0        0       0
                                                                                            Percentage Out of Compliance:     0%




7/13/2011                                                                                                               Page 15 of 37
OASAS MEDICAID SELF ASSESSMENT TOOL CASE RECORDS
 14. GROUP COUNSELING :
 PATIENT CASE #                                                    1   2   3   4   5   6   7        8        9       10     Total
 1. Was a billable Group Counseling Service Provided?                                                                        # of
                                                                                                                           Cases 0
 2. Were the appropriate billing codes used for the Group
 Counseling service(s) ?
 · Multiple family (adolescents only) (90849)
 · Alcohol and/or Substance Abuse (H0005) *(CPT 90853)
 *Note in those instances where a patient is dually
 enrolled in Medicaid /Medicare and the service and
 practitioner are reimbursable by Medicare the program
 may bill using a CPT code that corresponds to the
 service delivered AND the associated APG service
 category and weight.                                                                                                         0
 3. For each billable Group Counseling service is there
 documentation that indicates the minimum 60 minute time
 requirement was met? [(822-3.1(h)(6)]                                                                                        0
 4. Was there no more than one Group Counseling service
 provided and billed per patient service day? [(822-3.1(h)(6)]                                                                0
 5. Did a clinical staff member conduct the face-to-face Group
 Counseling service(s) as evidenced by their signature on the
 documentation? [(822-2.1(m)][(822-2.5(a)(1)]                                                                                 0
 6. Were there no more than 15 patients in each billed Group
 Counseling Service? [822-4.2(c)(3)]                                                                                          0
 7. Except for medication management, complex care, peer
 services and collateral contacts did the program limit billed
 services to no more than two services billed for on the date(s)
 of the Group Counseling service?                                                                                             0
                                                      TOTALS:      0   0   0   0   0   0   0        0        0        0       0
                                                                                           Percentage Out of Compliance:     0%




7/13/2011                                                                                                              Page 16 of 37
OASAS MEDICAID SELF ASSESSMENT TOOL CASE RECORDS
 15. COMPLEX COORDINATION OF CARE:
 PATIENT CASE #                                                      1   2   3   4   5   6   7        8        9       10     Total
 1. Was a billable Complex Coordination of Care Service                                                                        # of
 Provided?                                                                                                                   Cases 0
 2. Were the appropriate billing codes used for the Complex
 Coordination of Care service(s) ? (90882)                                                                                      0
 3. For each billable Complex Coordination of Care service is
 there documentation that indicates the minimum 45 minute
 time requirement was met? [(822-3.1(h)(5)]                                                                                     0
 4. For the selected patient record did the program limit billling
 to one Complex Coordination of Care service billed per patient
 visit day? [(822-3.1(h)(5)]                                                                                                    0
 5. Does the documentation indicate that the Complex
 Coordination of Care service(s) occur within 5 working days of
 patient visit to the program? [(822-3.1(h)(5)]                                                                                 0
 6. Did the program limit billing billable Complex Coordination
 of Care services to no more than three within an episode of
 care unless clinical staff document the clinical necessity and
 appropriateness of additional service in the
 treatment/recovery plan? [(822.3.1(h)(5))]                                                                                     0
                                                       TOTALS:       0   0   0   0   0   0   0        0        0        0       0
                                                                                             Percentage Out of Compliance:     0%




7/13/2011                                                                                                                Page 17 of 37
OASAS MEDICAID SELF ASSESSMENT TOOL CASE RECORDS
 16. BRIEF TREATMENT:
 PATIENT CASE #                                                      1   2   3   4   5   6   7        8        9       10     Total
 1. Was a billable Brief Treatment Service Provided?                                                                           # of
                                                                                                                             Cases 0
 2. Was the appropriate billing code used for the Brief
 Treatment service(s) (H0050)?
                                                                                                                                0
 3. For all billed Brief Treatment service is there
 documentation that indicates that the 15 minute minimum
 time requirement was met for the service(s) provided? [(822-
 3.1(h)(3)]                                                                                                                     0
 5. For the selected patient record did program limit billed Brief
 Treatment service to one per patient visit day? [(822-
 3.1(h)(3)]                                                                                                                     0
 6. Did a clinical staff member conduct the face-to-face Brief
 Treatment service(s) as evidenced by their signature on the
 documentation? [(822-2.1(c)][(822-2.5(a)(1)]                                                                                   0
 7. Except for medication management, complex care, peer
 services and collateral contacts did program limit total billed
 sevice to no more than two separate service categories on
 the date(s) of the Brief Treatment service(s)?
                                                                                                                                0
                                                        TOTALS:      0   0   0   0   0   0   0        0        0        0       0
                                                                                             Percentage Out of Compliance:     0%




7/13/2011                                                                                                                Page 18 of 37
OASAS MEDICAID SELF ASSESSMENT TOOL CASE RECORDS
 17. PEER SUPPORT SERVICES:
 PATIENT CASE #                                                    1   2   3   4   5   6   7        8        9       10     Total
 1. Was a billable Peer Support Service Provided?                                                                            # of
                                                                                                                           Cases 0
 2. Were the appropriate billing codes used for the Peer
 Support service(s) ? (H0038)                                                                                                 0
 3. For each billable Peer Support service is there
 documentation that indicates the minimum 30 minute time
 requirement was met? [(822-3.1(h)(12)]                                                                                       0
 4. Was there no more than one Peer Support service provided
 and billed per patient service day? [(822-3.1(h)(12)]
                                                                                                                              0
 5. Does the documentation indicate that an appropriately
 recognized Peer Advocate provided face-to-face, on-site Peer
 Support service(s) as evidenced by their signature on the
 documentation? [(822-2.1(z)][(822-2.5(a)(1)]
                                                                                                                              0
 7. Were no more than five billable Peer Support services
 within an episode of care unless clinical staff document the
 clinical necessity and appropriateness of additional service in
 the treatment/recovery plan? [(822.3.1(h)(12)]                                                                               0
                                                       TOTALS:     0   0   0   0   0   0   0        0        0        0       0
                                                                                           Percentage Out of Compliance:     0%




7/13/2011                                                                                                              Page 19 of 37
OASAS MEDICAID SELF ASSESSMENT TOOL CASE RECORDS
                          MEDICAID BILLING SELF-ASSESSMENT WORKSHEET INSTRUCTIONS - For Visit Dates After July 1, 2011
   Using the selected Patient Record(s) and corresponding Medicaid Remittance statement(s), complete the following information on the Self-Assessment
                                                                          Worksheet.
1. SCREENING:                       Enter "Y" for Yes or "N" for No as indicated, otherwise enter information as directed.

PATIENT CASE #                                                     11   12   13      14       15       16      17       18       19        20    Total
1. Was a billable Screening service provided?                                                                                                     # of
                                                                                                                                                Cases 0
2. Was the appropriate billing code used for the Screening
service (H0049)?                                                                                                                                   0
3. For the Screening service provided is there documentation
that indicates that the minimum 15 minute time requirement
was met for the service provided? [(822-3.1(h)(13)]                                                                                                0
4. Did a clinical staff member conduct the face-to-face
Screening Service as evidenced by their signature on the
documentation? [(822-2.1(ac)][(822-2.5(a)(1)]                                                                                                      0
5. For the selected patient record did program bill for only one
screen per episode of care? [(822-3.1(h)(13)]
                                                                                                                                                   0
                                                      TOTALS:      0    0    0        0       0        0        0        0        0        0       0
                                                                                                                Percentage Out of Compliance:     0%




7/13/2011                                                                                                                                   Page 20 of 37
OASAS MEDICAID SELF ASSESSMENT TOOL CASE RECORDS
2. BRIEF INTERVENTION:
PATIENT CASE #                                                     11   12   13   14   15   16   17      18       19        20    Total
1. Were billable Brief Intervention Service(s) Provided?                                                                           # of
                                                                                                                                 Cases 0
2. Was the appropriate billing code used for all Brief
Intervention service(s) provided (H0050)?                                                                                           0
3. For the selected patient record did the program limit total
billed pre-admission Brief Intervention claims to no more than
three? [(822-3.1(h)(2)]                                                                                                             0
4. For each billable Brief Intervention service is there
documentation that indicates that the 15 minute minimum
time requirement was met for the service(s) provided? [(822-
3.1(h)(2)]                                                                                                                          0
5. For the selected patient record did the program limit billed
Brief Intervention service to one service per patient per visit
date? [(822-3.1(h)(2)]                                                                                                              0
6. Did a clinical staff member conduct the face-to-face Brief
Intervention service(s) as evidenced by their signature on the
documentation? [(822-2.1(b)][(822-2.5(a)(1)]
                                                                                                                                    0
                                                         TOTALS:   0    0    0    0    0    0    0        0        0        0       0
                                                                                                 Percentage Out of Compliance:     0%




7/13/2011                                                                                                                    Page 21 of 37
OASAS MEDICAID SELF ASSESSMENT TOOL CASE RECORDS
3. PRE-ADMISSION ASSESSMENT :
PATIENT CASE #                                                   11   12   13   14   15   16   17      18       19        20    Total
1. Were billable Pre-Admission Assessment services                                                                               # of
provided?                                                                                                                      Cases 0
2. Were the appropriate billing codes used for all Pre-
Admisson Assessment service(s) ?
 Brief (15 minutes)(T1023)
 Normative (30 minutes)(H0001)
 Extended (75 minutes)(H0002 or CPT 90801*)
* For those instances where a patient is dually enrolled in
Medicaid/Medicare and the service and practitioner are
reimbursable by Medicare the program may bill using a
CPT code that corresponds to the service delivered AND
the associated APG service category and weight.
                                                                                                                                  0
3. Were there no more than three pre-admission Assessment
services billed for the patient. [(822-3.1(h)(1)]                                                                                 0
4.Did the program deliver and bill for only one Extended
Assessment? [(822-3.1(h)(1)]                                                                                                      0
5. For the selected patient record is there documentation that
indicates minimum time requirements for all billable Pre-
Admisson Assessment service(s) provided were met as
follows:
 Brief (15 minutes)
 Normative (30 minutes)
 Extended (75 minutes) [(822-3.1(h)(1)(i-iii)]                                                                                   0
6. Did program limit Pre-Admisson Assessment service(s)
provided and billed to one per patient visit date? [(822-
3.1(h)(1)]                                                                                                                        0
7. Did a clinical staff member conduct the face-to-face
Assessment service(s) as evidenced by their signature on the
documentation? [(822-2.1(a)][(822-2.5(a)(1)]                                                                                      0
8. Do the patient case records contain the name of the
authorized QHP who made the admission decision as
documented by their signature and date? [822-4.3(e)]                                                                              0
                                                       TOTALS:   0    0    0    0    0    0    0        0        0        0       0
                                                                                               Percentage Out of Compliance:     0%



7/13/2011                                                                                                                  Page 22 of 37
OASAS MEDICAID SELF ASSESSMENT TOOL CASE RECORDS
                            Enter the Admission Date
4. COMPREHENSIVE EVALUATION:
PATIENT CASE #                                                  11   12   13   14   15   16   17      18       19        20    Total
                                                                                                                                # of
1. Is there a Comprehensive Evaluation in the Case Record?                                                                    Cases 0

               Enter the Date of the Comprehensive Evaluation
2. Are comprehensive evaluations completed by staff within
45 days of admission? [822-4.4(a), (e)]
3. Do the evaluations include the dated signature of the
Qualified Health Professional responsible for the evaluation
and the person responsible for completing it? [822-4.4(c)]
[822-4.4(a), (e)]
                                                      TOTALS:   0    0    0    0    0    0    0        0        0        0       0
                                                                                              Percentage Out of Compliance:     0%




7/13/2011                                                                                                                 Page 23 of 37
OASAS MEDICAID SELF ASSESSMENT TOOL CASE RECORDS
5. COMPREHENSIVE TREATMENT/RECOVERY PLANNING:
PATIENT CASE #                                                  11   12   13   14   15   16   17      18       19        20    Total
1. Is there a Comprehensive Treatment/Recovery Plan in the                                                                      # of
case record?                                                                                                                  Cases 0

 Enter the Date of Comprehensive Treatment/Recovery Plan
2. Are the comprehensive treatment/recovery plans approved
within 45 days of admission (determined by latest dated
signature of MDT)? [822-4.5(a)]                                                                                                  0
3. Are the comprehensive treatment/recovery plans reviewed
and agreed upon in a case conference by a multidisciplinary
team (MDT), and be signed and dated by all MDT members at
or sometime following the case conference? [822-4.5(a), 822-
4.5(c)(9)]                                                                                                                       0
4. Are the comprehensive treatment/recovery plans approved
signed and dated by the Medical Director or other physician
employed by the outpatient program within 10 days of review
and approval by the MDT? [822-4.5(c)(10)] (Note if the
physician is a member and signatory of the MDT this
regulatory requirement is satisfied)
                                                                                                                                 0
5. Are the treatment plans signed by the responsible clinical
staff member (primary counselor)? [822-4.5(c)(6, 10)]
                                                                                                                                 0
6. Is the entire treatment/recovery plan, once established,
thoroughly reviewed and revised at least every 90 calendar
days for the first year and at least every 180 calendar days
thereafter as evidenced by the the dated signature of a
member of the multi-disciplinary team; [822-4.5(g)]
                                                                                                                                 0
                                                     TOTALS:    0    0    0    0    0    0    0        0        0        0       0
                                                                                              Percentage Out of Compliance:     0%




7/13/2011                                                                                                                 Page 24 of 37
OASAS MEDICAID SELF ASSESSMENT TOOL CASE RECORDS
6. MEDICATION MANAGEMENT COMPLEX:
PATIENT CASE #                                                      11   12   13   14   15   16   17      18       19        20    Total
1. Were billable Medication Management Complex service(s)                                                                           # of
provided?                                                                                                                         Cases 0
2. Was the appropriate billing code used for all Medication
Management Complex service(s) provided (90862)?                                                                                      0
3. For all billable Medication Management Complex
service(s) is there documentation that indicates that the 15
minute minimum time requirement was met for the
service(s) provided? [822-3.1(h)(10)(ii)]
                                                                                                                                     0
4. Did program limit all Medication Management Complex
service(s) provision and billing to one service per patient visit
date? [822-3.1(h)(10)]                                                                                                               0
                                                       TOTALS:      0    0    0    0    0    0    0        0        0        0       0
                                                                                                  Percentage Out of Compliance:     0%
7. ADDICTION MEDICATION INDUCTION (AMI):
PATIENT CASE #                                                      11   12   13   14   15   16   17      18       19        20    Total
1. Were billable Addiction Medication Induction services(s)                                                                         # of
provided?                                                                                                                         Cases 0
2. Was the appropriate billing code used for all Addiction
Medication Induction service(s) (H0014)?                                                                                             0
3. For all billable Addiction Medication Induction services(s)
is there documentation that indicates that the 30 minute
minimum time requirement was met for the service(s)
provided?                                                                                                                            0
[822-3.1(h)(10)(iii)]limit Addiction Medication Induction
4. Did the program
services(s) provision and billing to one service per patient
visit date? [822-3.1(h)(10)(ii)]                                                                                                     0
5. Did a Prescribing Professional conduct the Addiction
Medication Induction service(s) as evidenced by their
signature on the documentation? [(822-2.1(t)][(822-
2.5(a)(1)]                                                                                                                           0
                                                       TOTALS:      0    0    0    0    0    0    0        0        0        0       0
                                                                                                  Percentage Out of Compliance:     0%




7/13/2011                                                                                                                     Page 25 of 37
OASAS MEDICAID SELF ASSESSMENT TOOL CASE RECORDS
8. MEDICATION MANAGEMENT ROUTINE:
PATIENT CASE #                                                  11   12   13   14   15   16   17      18       19        20    Total
1. Were billable Medication Management Routine service(s)                                                                       # of
provided?                                                                                                                     Cases 0
2. Was the appropriate billing code used for all of the
Medication Management Routine service(s) provided
(M0064))?                                                                                                                        0
3. For all billed Medication Management Routine service(s)
is there documentation that indicates that the 10 minute
minimum time requirement was met for the service(s)
provided? [822-3.1(h)(10)(i)]                                                                                                    0
4. Did program limit Medication Management Routine service
provision and billing to one service per patient visit date?
[822-3.1(h)(10)(i-ii)]
                                                                                                                                 0
5. Did a Prescribing Professional conduct all of the face-to-
face Medication Management Routine service(s) as
evidenced by their signature on the documentation? [(822-
2.1(ab)][(822-2.5(a)(1)]                                                                                                         0
                                                      TOTALS:   0    0    0    0    0    0    0        0        0        0       0
                                                                                              Percentage Out of Compliance:     0%




7/13/2011                                                                                                                 Page 26 of 37
OASAS MEDICAID SELF ASSESSMENT TOOL CASE RECORDS
9. MEDICATION ADMINISTRATION AND OBSERVATION:
PATIENT CASE #                                                11   12   13   14   15   16   17      18       19        20    Total
1. Were billable Medication Administrative and Observation                                                                    # of
service(s) provided?                                                                                                        Cases 0
2. Were the appropriate billing code(s) used for the
Medication Administrative and Observation service(s) (H0020
Methadone) (H0033 Oral Medication)?                                                                                            0
3. Was there no more than one Medication Administrative
and Observation service provided and billed per patient
service day? [822-3.1(h)(9)]                                                                                                   0
4. Did a medical staff member conduct all the face-to-face
Medication Administrative and Observation service(s) as
evidenced by their signature on the documentation? [(822-
2.1(s)][(822-2.5(a)(1)]                                                                                                        0


                                                   TOTALS:
                                                              0    0    0    0    0    0    0        0        0        0       0
                                                                                            Percentage Out of Compliance:     0%




7/13/2011                                                                                                               Page 27 of 37
OASAS MEDICAID SELF ASSESSMENT TOOL CASE RECORDS
10. COLLATERAL CONTACT:
PATIENT CASE #                                                    11   12   13   14   15   16   17      18       19        20    Total
1. Were billable Collateral Contact Service(s) Provided?                                                                          # of
                                                                                                                                Cases 0
2. Were the appropriate billing codes used for the Collateral
Contact service(s) (T1006 or CPT 90846*)?
* For those instances where a patient is dually enrolled in
Medicaid/Medicare and the service and practitioner are
reimbursable by Medicare the program may bill using a
CPT code that corresponds to the service delivered AND
the associated APG service category and weight.
                                                                                                                                   0
3. For the selected patient record did the program limit billed
Collateral Contact services to no more than five; within an
episode of care? [822-3.1(h)(4)]                                                                                                   0
4. For each billable Collateral Contact service is there
documentation that indicates the 30 minute minimum time
requirement was met? [822-3.1(h)(4)]                                                                                               0
5. For the selected patient record did the program limit billed
Collateral Contact service to one per patient visit date?
[822-3.1(h)(4)]                                                                                                                    0
6. Did a clinical staff member conduct the face-to-face
Collateral Contact service(s) as evidenced by their signature
on the documentation? [(822-2.1(h)][(822-2.5(a)(1)]
                                                                                                                                   0
                                                       TOTALS:    0    0    0    0    0    0    0        0        0        0       0
                                                                                                Percentage Out of Compliance:     0%




7/13/2011                                                                                                                   Page 28 of 37
OASAS MEDICAID SELF ASSESSMENT TOOL CASE RECORDS

11. OUTPATIENT REHABILITATION: (Only programs that are CERTIFIED by OASAS as Outpatient Rehabilitation may bill for such service)
PATIENT CASE #                                                      11   12   13   14      15       16      17       18       19        20    Total
1. Were billable Outpatient Rehabilitation Service(s)                                                                                          # of
Provided?                                                                                                                                    Cases 0
2. Were the appropriate billing codes used for the Outpatient
Rehabilitation service(s)?
 Partial: Day 2-4 hours (H2001) OR
 Full: four hour and above (H2036)                                                                                                             0
3. For each billable Outpatient Rehabilitation service is there
documentation that indicates the minimum time requirement
was met? [822-3.1(h)(11)(i-ii)]
 Partial Day - 2-4 hours OR
 Full Day - 4+ hours                                                                                                                           0
4. Did program limit billed Outpatient Rehabilitation services to
one per patient visit day? [822-3.1(h)(11)]
                                                                                                                                                0
5. With the exception of medication management, complex
care, peer services and collateral contacts; did the program
exclude billing for any other services billed for on the same
date(s) as the Outpatient Rehabilitation service? [822-
3.1(h)(11)]
                                                                                                                                                0
                                                        TOTALS:     0    0    0    0        0       0        0        0        0        0       0
                                                                                                             Percentage Out of Compliance:     0%




7/13/2011                                                                                                                                Page 29 of 37
OASAS MEDICAID SELF ASSESSMENT TOOL CASE RECORDS
12. INTENSIVE OUTPATIENT SERVICES (IOS): (NOTE: Does not require separate OASAS Certification)
PATIENT CASE #                                                     11   12   13   14     15      16   17      18       19        20    Total
1. Were billable Intensive Outpatient Service(s) Provided?                                                                              # of
                                                                                                                                      Cases 0
2. Was the appropriate billing codes used for the Intensive
Outpatient service(s)? (S9480)                                                                                                           0
3. For each billable Intensive Outpatient service is there
documentation that indicates the minimum time requirement
was met? [822-3.1(h)(8)]
 9 hours of treatment sessions per week.
 3 hours per day.                                                                                                                       0
4. For the selected patient record did the program limit patient
participation in IOS to no more than six weeks of Intensive
Outpatient services provided unless there was clinical
justification for additional time? [822-3.1(h)(8)]
                                                                                                                                         0
                                                      TOTALS:      0    0    0    0      0       0    0        0        0        0       0
                                                                                                      Percentage Out of Compliance:     0%




7/13/2011                                                                                                                         Page 30 of 37
OASAS MEDICAID SELF ASSESSMENT TOOL CASE RECORDS
13. INDIVIDUAL COUNSELING:
PATIENT CASE #                                                     11   12   13   14   15   16   17      18       19        20    Total
1. Was a billable Individual Counseling Service Provided?                                                                          # of
                                                                                                                                 Cases 0
2. Was the appropriate billing codes used for the Individual
Counseling service(s) ?
 Brief 25 minutes (G0396) or CPT 90804*
 Normative 45 minutes (G0397) or CPT 90806*

*For those instances where a patient is dually enrolled in
Medicaid/Medicare and the service and practitioner are
reimbursable by Medicare the program may bill using a
CPT code that corresponds to the service delivered AND
the associated APG service category and weight.

                                                                                                                                    0
3. For each billed Individual Counseling service is there
documentation that indicates minimum time requirement were
met for the service(s) provided as follows:
 Brief (25 minutes)
 Normative (45 minutes) [(822-3.1(h)(7)]                                                                                           0
4. For the selected patient record did the program limit billing
to one Individual Counseling service per patient visit ? [(822-
3.1(h)(7)]
                                                                                                                                    0
5. Did a clinical staff member conduct the face-to-face
Individual Counseling service(s) as evidenced by their
signature on the documentation? [(822-2.1(m)][(822-
2.5(a)(1)]                                                                                                                          0
6. Except for medication management, complex care, peer
services and collateral contacts did the program limit billed
services to no more than two for the visit date(s) of the
Individual Counseling service?                                                                                                      0
                                                      TOTALS:      0    0    0    0    0    0    0        0        0        0       0
                                                                                                 Percentage Out of Compliance:     0%




7/13/2011                                                                                                                    Page 31 of 37
OASAS MEDICAID SELF ASSESSMENT TOOL CASE RECORDS
14. GROUP COUNSELING:
PATIENT CASE #                                                    1   2   3   4   5   6   7        8        9        10    Total
1. Was a billable Group Counseling Service Provided?                                                                        # of
                                                                                                                          Cases 0
2. Were the appropriate billing codes used for the Group
Counseling service(s) ?
 Multiple family (adolescents only) (90849)
 Alcohol and/or Substance Abuse (H0005) *(CPT 90853)
*Note in those instances where a patient is dually
enrolled in Medicaid /Medicare and the service and
practitioner are reimbursable by Medicare the program
may bill using a CPT code that corresponds to the
service delivered AND the associated APG service
category and weight.
                                                                                                                             0
3. For each billable Group Counseling service is there
documentation that indicates the minimum 60 minute time
requirement was met? [(822-3.1(h)(6)]                                                                                        0
4. Was there no more than one Group Counseling service
provided and billed per patient service day? [(822-3.1(h)(6)]
                                                                                                                             0
5. Did a clinical staff member conduct the face-to-face Group
Counseling service(s) as evidenced by their signature on the
documentation? [(822-2.1(m)][(822-2.5(a)(1)]
                                                                                                                             0
6. Were there no more than 15 patients in each billed Group
Counseling Service? [822-4.2(c)(3)]                                                                                          0
7. Except for medication management, complex care, peer
services and collateral contacts did the program limit billed
services to no more than two services billed for on the date(s)
of the Group Counseling service?                                                                                             0
                                                     TOTALS:      0   0   0   0   0   0   0        0        0        0       0
                                                                                          Percentage Out of Compliance:     0%




7/13/2011                                                                                                             Page 32 of 37
OASAS MEDICAID SELF ASSESSMENT TOOL CASE RECORDS
15. COMPLEX COORDINATION OF CARE:
PATIENT CASE #                                                      11   12   13   14   15   16   17      18       19        20    Total
1. Was a billable Complex Coordination of Care Service                                                                              # of
Provided?                                                                                                                         Cases 0
2. Were the appropriate billing codes used for the Complex
Coordination of Care service(s) ? (90882)                                                                                            0
3. For each billable Complex Coordination of Care service is
there documentation that indicates the minimum 45 minute
time requirement was met? [(822-3.1(h)(5)]
                                                                                                                                     0
4. For the selected patient record did the program limit billling
to one Complex Coordination of Care service billed per patient
visit day? [(822-3.1(h)(5)]                                                                                                          0
5. Does the documentation indicate that the Complex
Coordination of Care service(s) occur within 5 working days of
patient visit to the program? [(822-3.1(h)(5)]
                                                                                                                                     0
6. Did the program limit billing billable Complex Coordination
of Care services to no more than three within an episode of
care unless clinical staff document the clinical necessity and
appropriateness of additional service in the
treatment/recovery plan? [(822.3.1(h)(5))]                                                                                           0
                                                      TOTALS:       0    0    0    0    0    0    0        0        0        0       0
                                                                                                  Percentage Out of Compliance:     0%




7/13/2011                                                                                                                     Page 33 of 37
OASAS MEDICAID SELF ASSESSMENT TOOL CASE RECORDS
16. BRIEF TREATMENT:
PATIENT CASE #                                                      11   12   13   14   15   16   17      18       19        20    Total
1. Was a billable Brief Treatment Service Provided?                                                                                 # of
                                                                                                                                  Cases 0
2. Was the appropriate billing code used for the Brief
Treatment service(s) (H0050)?                                                                                                        0
3. For all billed Brief Treatment service is there
documentation that indicates that the 15 minute minimum
time requirement was met for the service(s) provided? [(822-
3.1(h)(3)]                                                                                                                           0
4. For the selected patient record did program limit billed Brief
Treatment service to one per patient visit day? [(822-
3.1(h)(3)]                                                                                                                           0
5. Did a clinical staff member conduct the face-to-face Brief
Treatment service(s) as evidenced by their signature on the
documentation? [(822-2.1(c)][(822-2.5(a)(1)]
                                                                                                                                     0
7. Except for medication management, complex care, peer
services and collateral contacts did program limit total billed
sevice to no more than two separate service categories on
the date(s) of the Brief Treatment service(s)?
                                                                                                                                     0
                                                       TOTALS:      0    0    0    0    0    0    0        0        0        0       0
                                                                                                  Percentage Out of Compliance:     0%




7/13/2011                                                                                                                     Page 34 of 37
OASAS MEDICAID SELF ASSESSMENT TOOL CASE RECORDS
17. PEER SUPPORT SERVICES:
PATIENT CASE #                                                    11   12   13   14   15   16   17      18       19        20    Total
1. Was a billable Peer Support Service Provided?                                                                                  # of
                                                                                                                                Cases 0
2. Were the appropriate billing codes used for the Peer
Support service(s) ? (H0038)                                                                                                       0
3. For each billable Peer Support service is there
documentation that indicates the minimum 30 minute time
requirement was met? [(822-3.1(h)(12)]                                                                                             0
4. Was there no more than one Peer Support service provided
and billed per patient service day? [(822-3.1(h)(12)]
                                                                                                                                   0
5. Does the documentation indicate that an appropriately
recognized Peer Advocate provided face-to-face, on-site Peer
Support service(s) as evidenced by their signature on the
documentation? [(822-2.1(z)][(822-2.5(a)(1)]
                                                                                                                                   0
7. Were no more than five billable Peer Support services
within an episode of care unless clinical staff document the
clinical necessity and appropriateness of additional service in
the treatment/recovery plan? [(822.3.1(h)(12)]                                                                                     0
                                                      TOTALS:     0    0    0    0    0    0    0        0        0        0       0
                                                                                                Percentage Out of Compliance:     0%




7/13/2011                                                                                                                   Page 35 of 37
                                         SECTION ANALYSIS SCORING SUMMARY

Section #                                  Section Name                                       % OUT OF COMPLIANCE*
     1      Screening                                                                                  0%
     2      Brief-Intervention                                                                         0%
     3      Pre-Admission Assessment                                                                   0%
     4      Comprehensive Evaluation                                                                   0%
     5      Comprehensive Treatment/Recovery Planning                                                  0%
     6      Medication Management Complex                                                              0%
     7      Addiction Medication Induction (AMI)                                                       0%
     8      Medication Management Routine                                                              0%
     9      Medication Administration and Observation                                                  0%
    10      Collateral Contact                                                                         0%
    11      Outpatient Rehabilitation                                                                  0%
    12      Intensive Outpatient Services                                                              0%
    13      Individual Counseling                                                                      0%
    14      Group Counseling                                                                           0%
    15      Complex Coordination of Care                                                               0%
    16      Brief Treatment                                                                            0%
    17      Peer Support Services                                                                      0%


*Indicates possible areas of concern eg., Medicaid disallowance, regulatory non-compliance.


**Please note that percentage of non-compliance may be higher for some catagories due to a small sample size. If this is
a concern it is suggested that you sample other case records with that particular service to determine compliance level.
                              % OUT OF COMPLIANCE*




0%   0%   0%   0%   0%   0%   0%   0%   0%   0%   0%   0%   0%   0%   0%   0%   0%

				
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