When do I use Other Activities? This is a great place for you to give credit to the great work that you are doing with your clients at every visit! There is a connection between the work you do and selecting an other activity from the list. This is especially important when you complete an assessment. Be sure that when you do select an other activity, your main progress note reflects the use of that specific activity. *Other Activities Type ***Suicide Risk Assessment - MDD Dx *Adult Smoking Cessation & Counseling *Adult Unhealthy Alcohol Use Brief Counseling *F/U Plan for Depression Ages 12 17 & 18+ *Counseling for Depression Age 18+ Advocacy Alcohol & Drug Assessment 3-10 minutes 11+ minutes 15-30 minutes Document this Other Activity for adults with new diagnosis or recurrent Dx of MDD Document this Other Activity for adolescents w/ MDD Dx, each encounter Document this Other Activity & Smoking Status during same encounter Duration MUST be entered (3-10 minutes or 11 minutes+) Acknowledge Preventative Care and Screening: Tobacco Use Screening and Cessation Intervention flag Document this Other Activity for all scrore 8 Must be documented on same day AUDIT is administered Acknowledge the Preventative Care and Screening: Unhealthy Alcohol Use: Screening and Brief Counseling flag when AUDIT is completed and client received brief counseling due to a score of 8 or higher on the AUDIT Document this Other Activity on the same day PHQA/PHQ9 is administered & had a score of 10 Acknowledge the Preventative Care and Screening: Screening for Clinical Depression and Follow-Up Plan flag when PHQA/9 is completed and follow-up plan (e.g. medication prescribed, suicide risk assessment completed, etc.) is documented. Can be entered on any event for depression Must complete an alcohol or drug assessment Clients with Major Depressive Disorder, a Suicide Risk Assessment is conducted (e.g. past history, psychiatric symptoms, current stressors and protective factors, etc.) Clinic Measure/Clinical Quality Measure 3085FHH* Counseling around smoking and tobacco use cessation for clients who smoke Clinic Measure/Clinical Quality Measure 99406/7HH* Counseling around unhealthy alcohol use (e.g. AUDIT score) for 15-30mins Clinic Measure* Follow up related to depression and depressive symptoms (e.g. interventions, assessments, referrals, treatment planning, etc.) for all adolescents & adult clients Clinic Measure* Counseling related to depression for client s with NEW diagnosis of depression Clinical Quality Measure* Advocating for a client to receive/participate in services (e.g. calling a referral source or a school in session, helping client obtain funding, etc.) Completion of an assessment related to client alcohol or drug use (e.g. AUDIT, Cage Aid Questionnaire, etc.)
*Other Activities Type Alcohol and/or Drug Case Management Behavioral Health Screening Care Coordination Cognitive Behavioral Therapy Comprehensive Multidisciplinary Evaluation Crisis intervention - Alcohol and/or Drug Services Eye Movement Desensitization & Reprocessing (EMDR) Family/Natural Support Housing Only used by those with training in EMDR Evaluation must include staff across multiple disciplines (e.g. counselor & psychiatrist) Must be done at the outpatient level H0001HH* Case management or related services for client s alcohol and drug use (e.g. referral to AA/NA group, etc.) H0006HH* Behavioral health screening to determine eligibility for admission to treatment program (e.g. comprehensive assessment for placement into most appropriate program, screening for alcohol use to transfer client to ASP, etc.) H0002HH* Coordinating care with other providers (e.g. client self-report of medical information, calls to collaterals to obtain client care information, medical record requests, etc.) Use of interventions related to CBT (e.g. relaxation techniques, reducing negative self-talk, challenging maladaptive thought patterns, etc.) EBP* Evaluation of a client with an interdisciplinary team of staff (e.g. ambulatory detox, team members brought into psychiatrist appointment) H2000HH* Crisis intervention implemented during an alcohol and/or drug service (e.g. ambulatory detox, calling emergency services, etc.) H0007HH* Use of EMDR intervention to improve client functioning EBP* Use of family and/or natural supports in treatment (e.g. family therapy session, including a significant other in an individual therapy session, etc.) Focus in service on obtaining housing for client
*Other Activities Type IMR Interactive Complexity (Play Therapy/Language Line) Medication Training and Support Mental Health Assessment Motivational Interviewing mystrength Peer Support Psycho-Education Psychosocial Rehabilitation Services SA Family Counseling SA Treatment Planning SA Skill Building 30 minute units 20-30 minutes per session 15 minute units Only for non-physicians 15 minutes This does not include play therapy on its own Uses include when a client cannot communicate (such as due to language barrier) using methods to facilitate communication such as calling the Language Line Utilizes reeducation, support and reassurance, insight discussions, and occasional medication to affect behaviormodification through self-understanding. Family or significant other must be present Used along with any review or changes to treatment plan Acknowledge the Initiation and engagement of alcohol and other drug dependence treatment flag when client begins substance abuse treatment program individual sessions Use of illness management and recovery intervention to improve client functioning EBP* Individual psychophysiological therapy incorporating biofeedback training, with psychotherapy; Individual psychotherapy involving patient biofeedback training in which the patient learns how certain thought process, stimuli, and emotions effect their blood pressure, muscle tension, brain wave activity, etc. 90785HH* Training and support given to client around medication H0034HH* Completion of a mental health assessment H0031HH* Use of interventions related to MI (e.g. open questions, affirmations, motivation ruler, etc.) EBP* Giving information about or using activities from mystrength site with the client during the service Support provided by a Peer Required of all CCBHC s* Using psycho-education with client or family to help understanding and improve client functioning (e.g. psycho-education around anxiety or parenting skills, etc.) Usually refers to Supported Employment, Supported Education, Partial Care, and/or WRAP planning H2017HH* Alcohol and/or substance abuse services, family/couple s counseling T1006 Alcohol and/or substance abuse services, treatment plan development and/or modification T1007 Alcohol and/or substance abuse services, skills development T1012
*Other Activities Type SA Brief Intervention SA Therapy Socialization Trauma Focused Cognitive Behavioral Therapy Trauma Informed Care Treatment Team with Client WRAP Plan Development 15 minute units 15 minutes 30 minute units Must include staff across multiple disciplines, at least 1 of which is a non-physician qualified health care professional (e.g. counselor & psychiatrist) Brief intervention used during an alcohol or drug service H0050HH* Alcohol and/or drug services, brief intervention, per 15 minutes H0050* Intervention used to promote socialization of client (e.g. engagement in new activities, social skills education, etc.) Use of interventions related to TF-CBT (e.g. relaxation techniques, thought stopping, safety planning, etc.) EBP* Use of trauma informed practices to provide most appropriate care to client EBP* Medical team conference with interdisciplinary team of health care professionals, face-to-face with patient and/or family 99366HH* Working with the client to develop a WRAP plan THE FOLLOWING ARE PRIMARILY FOR PRESCRIBERS: *Other Activities Type *AOD Assessment for BiPolar Disorder Age 18+ Individual Therapy Add-On Service *Adult BMI Follow Up Prescriber use ONLY Prescriber use ONLY 30/45/60 minutes Important requirements Document this Other Activity for adults with new DX Bi Polar disorder Acknowledge Bipolar Disorder and Major Depression: Appraisal for alcohol or chemical substance abuse flag Document this Other Activity during same encounter out of range BMI is calculated Substance Use Assessment for clients with a NEW diagnosis of BiPolar Disorder. All other staff complete Comp Assess. Substance Use Addendum. Clinical Quality Measure* Therapy add on, in addition to time of Office Visit 90833/36/38HH* Any follow up done with an adult client relating to being out of the normal range for BMI, (e.g. follow up plan which may include healthy eating habits,
*Adult BMI Referral for Weight Assessment *Child/Adolescent Nutrition Counseling for BMI *Child/Adolescent Physical Activity Couns for BMI *Documentation of Current Medication Age 18+ Document this Other Activity during same encounter out of range BMI is calculated Document this Other Activity & BMI each encounter Document this Other Activity & BMI each encounter Sub-report on OV & PE reflects list of current medications; select each encounter *The items marked in red after some descriptions indicates the following: weight loss, etc. is documented) Clinic Measure/Clinical Quality Measure* Any referral for an adult for additional services related to their BMI being out of range (e.g. referral to a nutritionist, referral to weight loss specialist, etc.) Clinic Measure/Clinical Quality Measure* Counseling with a youth around nutrition related to their BMI being out of range (e.g. healthy eating habits, weight loss, etc.) Clinical Quality Measure* Counseling with a youth around physical activity related to their BMI being out of range (e.g. exercise options, etc.) Clinical Quality Measure* Current medications documented for adult clients includes prescribed medication, OTC, herbal & supplements with name, dosage, frequency & route Clinical Quality Measure* Clinical Quality Measure: Clinical Quality Measures are part of our Medicaid (Meaningful Use) & Medicare (Merit Based Incentive Payment System MIPS) Programs. We must report data annually. Demonstration of value based care results in a positive payment adjustment on our Medicare claims, lack of quality care results in a negative payment adjustment on our Medicare claims. Clinic Measure: Clinic Measures are the measures established by SAMSHA for CCBHC s. We must report on all Clinic Measures. It is important to complete the workflow for Clinic Measures as we need to ensure that all clients who meet the reporting criteria for the measure, are captured in the numerator. EBP: These are any evidence based practices that you may be using in your sessions. Be sure to include them as they represent the intervention you are using with the client (e.g. open questions, reflective listening, summarization, motivation ruler, and affirmations are a interventions used in Motivational Interviewing). Letter and Number Combination (e.g. 99366HH): These represent that this item is linked with a specific billing code. Required of all CCBHC s: This particular item is designated as required for CCBHC as a program and is a service available to all clients
Care Plus NJ, Inc. Quality Assurance / Corporate Compliance Documentation to Justify Effective Use of Resources There is an ever increasing emphasis on Behavioral Health providers justifying the services they provide to clients. This is evident by changes in the Joint Commission on Accreditation of HealthCare Organizations (JCAHO) standards of care, and in the findings of recent Medicaid audits both at Care Plus as well as other agencies. It should be noted that JCAHO has been designated as providing Deemed Status to providers under CMS Medicaid/Medicare programs. Changes in JCAHO are based on adoption of CMS standards. Justification of services includes two aspects. The first aspect is the level of documentation of the types of activities that occur within a session to justify the length of the service provided. This is critical with regard to compliance with documentation standards for reimbursement and has been the basis for audit citations. The question is whether or not the documentation includes sufficient information to justify the length of the session provided. The second aspect is the documentation of the effectiveness of the types of interventions, strategies and approaches implemented by the provider. CMS/Medicaid refers to this as effective use of resources and is the basis for JCAHO to include standards of care requiring use of standardized tools and instruments. This is more complicated and relates back to the treatment plan, as well as the use of progress notes to monitor client progress by session. One way to conceptualize this is to compare treatment planning to a scientific experiment. You collect information about a specific client (Comprehensive Assessment) and consult your clinical knowledge/library about various techniques, strategies, and approaches. You develop a clinical formulation (hypothesis) about which technique may work best with this client and how you will measure progress towards goals (Measurable objectives, Standardized Tools and Instruments). You implement your plan and document observations based on your plan. You document your observations in your progress notes. Your progress notes become a series of observations to assess if your intervention or approach is working as you expected. Each progress note should document implementation of the intervention or approach identified in the plan and include observations relative to the client s progress. The series of observations between treatment plan reviews should be the basis for assessing the effectiveness of the interventions. In addition, use of standardized tools and instruments at the time of the treatment plan review provides a more empirical measure of progress. The lack of measurable progress or the indication of deterioration is a signal that the intervention is not effective and requires a change to the planned intervention. Progress notes service events in Evolv include a memo field in which you should identify the relative clinical information (Observation) related to the course of treatment obtained during the session. Progress notes also include an Other Activities section with a drop down list from which you should choose activities that occurred during the session. Every progress note should minimally identify the intervention implemented by the provider during the session (e.g. Cognitive Behavioral Therapy, Motivational Interviewing, Adult Unhealthy Alcohol Use Brief Counseling, etc.).