GUIDELINES, DOCUMENTATION, AND BILLING PRESENTED BY: THE DEPARTMENT OF HEALTH CARE POLICY AND FINANCING AND THE DIVISION FOR DEVELOPMENTAL DISABILITIES.

GUIDELINES, DOCUMENTATION, AND BILLING

P R E S E N T E D BY:

T H E D E PA R T M E N T O F H E A LT H C A R E P O L I C Y A N D F I N A N C I N G

A N D T H E D I V I S I O N F O R D E V E L O P M E N TA L D I S A B I L I T I E S

Targeted Case Management

Background

Case Management in Colorado Administrative Case Management Case Management as a Waiver Service Targeted Case Management

Designated by Waiver

Overview

State Plan Benefit Entitlement Benefit

Targeted Population Persons with Developmental Disabilities; and Enrolled HCBS-DD, SLS, or CES; or Enrolled in Early Intervention Services; and Medicaid Eligible

CMS Assurances

The State Assures that: Clients will have free choice of providers Case management services will be provided in a

manner consistent with the client’s best interest Case management services will not be used to restrict

a client’s access to other services Clients will not be compelled to receive case

management services Case managers cannot authorize or deny other State

Plan services

Qualified Providers

Community Centered Boards Only legally authorized agencies to provide TCM to

individuals with DD in community settings

Case Managers Appropriate qualifications to provide TCM

Bachelor’s Degree, Five years experience in the field of developmental

disabilities, OR Some combination of education and experience

Purpose

Facilitate Enrollment

Service Plan Development

Service Monitoring Effective Efficient

Coordination of Services/Benefits Educational Mental Health Emotional Social Medical

Ensure Non Duplication of Services

Reimbursement

15 Minute IncrementsCMS CompliantHSRI FindingsAuditsBilling Codes

Reimbursement

Specifically Defined Activity and Purposeful Outcome

Example: Telephone contact to schedule IDT Meeting

Bill in 15 minute increments 1-15 minutes = 15 minutes

Continuous Activity with Separate tasks

Example: Record Review, Telephone Contact, Service Plan Revision Bill Total Time Spent

State of

Colorado

Reimbursement

Multiple Client Contact Example: Monitoring Visit with

4 Clients at the same Group Home Estimate time/unit per individual

Multiple Contacts – One Day Example: Client calls 10 times in

one day Professional Judgment Number of units billed should not exceed total

amount of time worked.

State of

Colorado

General Contacts

Direct Contacts Face-to-Face Email Correspondence

Indirect Contacts Consultation with supervisor for the purpose to plan

or coordinate need services Documentation of TCM Activities Documentation and Review of Documentation for the

purpose of the individual record Review and distribution of records for planning,

coordinating, assessing, and referral to services.

Billable Activities

Comprehensive Assessment and Periodic Reassessment

Determine need for: Medical, Educational, Social, Other Services

Examples: Client History Assist in accessing benefits e.g., Social Security and/or

Medicaid re-determination Obtain and review any relevant and/or required

assessments needed for service planning

Billable Activities

Service Plan Development Based on information collected through

assessment Specifies goals for meeting all service needs

Medical Social Educational Other Services

Activities to ensure client participation Work with individual and others to develop goals Identifies course of action

Billable Activities

Service and Support Coordination Coordination of the services being provided in the

Service Plan to ensure continuity of service provision

Referral and Related Activities Help individual obtain needed services and activities

and link them to the appropriate provider: Medical Social Educational Other Programs

Billable Activities

Monitoring and Follow Up Activities Services are:

Implemented and delivered according to Service Plan

Adequately meeting the individual’s need

Monitor changes in need

Make necessary changes/revisions Provide Notification

Billable Activities

Monitoring and Follow Up Activities cont.

Health & safety needs are met

Rights are respected

Client Satisfaction

Administrative Activities

Intake and Eligibility DeterminationReporting and Aggregating Data

Critical Incidents Complaints

Agency Meetings Case Management/Staff Training Professional Developmental

Utilization Review ULTC 100.2 SIS

Documentation

Benefits Utilization System

If it didn’t happen on the BUS, it didn’t happen . . .

Documentation

Reimbursement based on BUS Documentation Log notes document units Reports generated by the BUS

Support claims paid

Benefits Utilization System

If it didn’t happen on the BUS, it didn’t happen . . .

Documentation

Date The BUS will generate a date and time of entry CM should reflect within the log note the

date/time of the activity notedTime

Record when appropriate Pertinent to the activity

Units Drop Down Menu 15 Minute Increments Record Units up to 32 Units (8 Hours)

Documentation

Activity TCM activity that is being

performed Multiple related activities or activities

performed within a single day may be entered into a single log note

Must be a billable activity Type of contact

Direct Indirect

Documentation

Finding The observations, assessments, or

outcomes of the activity.

Follow Up Action The actions to be taken with the

information obtained from the activity When appropriate 

Considerations

Ethical and Professional Reporting

AppropriationBudget Neutrality

Questions?