Documentation and Billing

Documentation and the medical record should be organized and maintained in a way that demonstrates:

• Why the person came for services.
• What the problem is.
• How it will be treated.
• What has happened throughout the course of treatment.
• How it was resolved.

This chapter will review some basic components of documentation and how documentation relates to billing and revenue for your organization. Your tribal health organization (THO) will have its own specific policies, procedures, and forms that you will use in your practice. However, the core components of documentation are the same regardless of the form used.

Purpose and use of documentation:

• A record detailing a client's reason for seeking services and the related course of treatment.
• A permanent medical record.
• An essential aspect of providing sound, ethical care.
• Part of every client visit and interaction (even over the phone).
• An important component of professional development and supervision.
• A legal, professional, and financial requirement for your THO. It helps protect you against malpractice, grievances, and complaints.

Documentation in client records includes:

• Client demographic information.
• Consent to treatment and release of information (ROI).
• Referrals for treatment.
• Screenings and initial assessment.
• Treatment plan, including problem areas, diagnoses, treatment goals, and discharge plan.
• Progress notes for clinical files (notes, charting, and file maintenance should be completed during or after every client visit and always within 24 hours).
• Client encounter forms for billing and coding.

Documentation helps you to:

• Monitor changes in the client’s health and wellbeing.
• Coordinate care with multiple providers and provide information to future providers.
• Review previous treatment services and prioritize new ones.

Documentation records:

• The reason why the client is seeking behavioral health services. This includes documenting the medical necessity for services.
• Information related to the presenting problems (such as medical conditions, substance use, stress, or mental concerns).
• Relevant family or social history.
• All medications the client is taking.
• Your impression of the client during the visit.
• What the client says to you and what you observe during your time with the client.
• The client's response to the treatment or service provided.
• A plan for follow-up and continued care.

Documentation provides justification for the health care services billed to insurance companies and governmental agencies. Diagnosis or billing codes such as ICD, DSM, CPT, or HCPCS must be supported by the documentation in the record.

Know your employer’s policies regarding documentation.

• Your THO may require you to complete specific forms or to document specific information in electronic health records or systems, such as AKAIMS, RPMS, or CERNER.
• The behavioral health record summarizes the services you provided or coordinated. It is considered private and protected by law (see Chapter B-4: Confidentiality and Release of Information ). It may also be reviewed, audited, or subpoenaed by the court.
• Consult with your supervisor and organization to stay aware of current and new protocols for documentation or requirements for treatment reimbursement.
• Depending on your employing organization and certification, your services may be reimbursable by third parties, including Medicaid. In addition to organizational and accreditation standards , these third-party payers often influence the elements of documentation that are required.

In Alaska, BHA/Ps can provide services via two different healthcare models: the Community Behavioral Health Services (CBHS) model and a medical model that is most often referred to as the BHA State Plan Amendment (SPA). Regardless of the model under which you provide a service, you must be knowledgeable about and adhere to the documentation requirements specific to your chosen model.

• The CBHS model allows BHA/Ps to provide and bill for services as a "Clinical Associate" or "Substance Use Counselor." To understand what services can be provided under this model and the detailed requirements for documentation, refer to the State of Alaska's Integrated Behavioral Health Regulations website.
• The SPA model requires BHA/Ps to be certified before they can provide services that are designated by their level of certification. User tools, such as the SPA FAQ, BHA Superbill, and a template for Progress Notes, can be found on the ANTHC BHA program website.

The client record should include all documents related to the client. Specific items will vary according to the services each client receives, and may include:

• Signed Consent to Treatment documents.
• Signed Release of Information (ROI).
• Individual services (copies of any screening, intake, or assessment documents completed).
• Treatment plan.
• Progress notes.

Any type of contact should be included in the record, including:

• Any attempt to contact the client and family.
• Actual contacts with the client and family.
• Contacts with referral organizations or providers.

You should receive documentation training through your organization and supervisor. A documentation course is required for your certification and is offered by ANTHC. You may also decide to make your own documentation reference file with examples so you know how to complete things correctly.

General guidelines for documentation:

• Record each session in the health record immediately, if possible. Set aside time each day to complete your documentation.
• Be aware of whether you are documenting the system under the SPA model or CBHS model. Records maintained under the CBHS are protected from view by providers under the medical model. Records maintained under the SPA are visible by medical providers. Regardless of the model, you should be cautious about the amount of detail you include and only include information that is clinically relevant.
• Use words that are clear and easy to read.
• If you are using a paper-based system:
  • Use a pen with black or dark-colored ink. Never use pencil. Avoid felt-tip pens.
  • Don’t use Post-its or sticky notes.
  • If you make a mistake, draw a single line through the entry. Never erase, use correction fluids, cross out, or scribble over what you wrote.
• Sometimes the client will discuss other people in a session. Do not include identifying information, such as name, for these people. Instead, refer to the relationship, position, or title (e.g., parent, sister, spouse, supervisor, or community member).

THOs may document client visits differently or use different formats. The most common formats for documenting this information include S.O.A.P. (Subjective, Objective, Assessment, Plan) and D.A.P (Data, Assessment, Plan); each of these is described below.

Your employer will specify which format you should use. Whichever the format your organization uses, the contents of progress notes will be similar. You will record:

• Basic client identifiers, such as the client’s name, reason for today’s visit, and chief complaint.
• Date of service and status of informed consent.
• Start and end time of the visit.
• Identified risk factors.
• Clinically relevant family and social history.
• Progress towards treatment goals.
• Response to and changes in treatment.
• Any changes in diagnosis.
• What the client reports to you (e.g., “I am depressed,” “I can’t sleep,” or “I drink a lot”). This is referred to as Subjective information.
• What you can see, hear, smell, count, or measure (e.g., “The client looks like he hasn’t slept or bathed recently"). This is referred to as Objective information. In some documentation formats, the subjective and objective information are documented in the same section, referred to as Data.
• What you think is going on, how the client responded to the intervention you provided, and a summary of your professional opinion about the client's progress towards treatment goals (e.g., “The client's stress seems to increase when he is around people who have been drinking. The client talked about and considered different ways to avoid or get out of these situations. Practicing these coping strategies will help him better manage his triggers for drinking."). This is referred to as your Assessment.
• What happens next, including an action plan for how to continue supporting the client towards his treatment goals (e.g., “Instructed the client to practice using some of his identified coping skills over the weekend and attend the planned group session next Wednesday.”). This is referred to as the Plan.

Organizations' templates can be different because they are meeting different requirements, such as for accreditation or billing. This template is one example that meets some of the common documentation requirements for progress notes. In the template, the "presenting problem" should cover Subjective/Objective or Data, the "intervention" summarizes and provides examples of what you did to help the client address the presenting problem and treatment goals, the "response" addresses the Assessment of the client's progress toward treatment goals, and the "follow-up plan" addresses the Plan for client homework, case management needs, date and time of next appointment, and/or conclusion of services.

Progress notes must also include your legible written or electronic signature and credentials. For paper records, protect the record’s integrity by signing your name at the end of the entry, leaving no empty space between the entry and your signature. Some documents may need additional signatures from your supervisor or other behavioral health care providers. Consult with your supervisor to confirm your organization's signature requirements.

Some clients may feel uncomfortable knowing that you are documenting your work with them. You might say, “As we talk, I’m going to write some things down so that I don't forget what you said. Is that okay?” If a client remains uncomfortable, explain that their records and all related documentation are private and protected by law. Assure the client that you won’t talk about the visit with anybody who is not part of the treatment team.

Some people still may not feel comfortable with you writing anything down during the counseling session itself. In those cases, respect their wishes and document these visits immediately after the session.

Even for clients who are comfortable with note-taking, writing too much during the visit can come between you and your client’s therapeutic relationship. Finding a good balance is important!

Consult with your supervisor to be clear about who has access to client records within your electronic health record system. More specifically, if you work in an integrated health setting, your client's files may be viewable by non-behavioral health providers. Given the sensitive nature of behavioral health sessions, it is especially important that you balance the need for privacy with the need for enough detail to justify medical necessity and to document how the treatment addresses their presenting problem and goals. Therefore, limit your documentation to the minimum information required to accomplish this.

The revenue cycle refers to the way health care services and processes are managed, including making sure they meet different requirements and that the overall system runs efficiently. It includes the following functions.

• Admission and Registration: Making sure that all patient data, including addresses, phone numbers, employers, current insurance information, etc., is correct from the time a client accesses services. Claims can be denied for inaccurate information. This creates extra work for office billing staff and potentially results in lost money for the organization. This function may also include helping clients with processes related to their service eligibility, including assistance with applications or preauthorization requirements.
• Provider Documentation: Making sure that all services that were provided to a client in the course of a visit are adequately documented in the chart and meet all clinical information and compliance requirements. This includes information related to medical necessity for services, documentation supporting the diagnosis, and documenting information about the client's progress towards treatment goals.
• Patient Record Coding and Data Entry: Making sure that trained staff accurately and quickly assign and/or review procedural and diagnosis codes to describe a patient visit. These codes are required in order for your organization to bill and get paid for the specific services you provided. As a provider, it's important for you to know what services you are permitted to provide based on your certification level and supervisor's approval. Familiarize yourself with the BHA Superbill, which outlines the specific codes and services certified BHA/Ps can provide and offers space to identify codes related to the client's presenting problem or diagnosis.
• Revenue Capture: Overseeing an organization's process for tracking the specific services, supplies, and pharmaceuticals provided during all client and patient visits. All services and resources provided to the client should be documented in the health record.
• Billing: Making sure that claims sent to third-party payers are accurate and timely and meet all regulatory and policy requirements and deadlines. The absence of required information can result in denied claims, lost revenue, or a fine that the organization must pay back.
• Collections and A/R Management: Monitoring billing claims that have been sent to payers to ensure that they are paid accurately and promptly. This includes monitoring claims that have been denied and the process for the Accounts Receivable (A/R) department to submit appeals when necessary. It also includes monitoring the payment of claims in order to identify opportunities to improve the revenue cycle.
• Accounts Receivable & File Maintenance: Reviewing, maintaining, and updating procedures related to individual services, including any changes in requirements or costs for the service..

As the regulations overseeing tribal billing and reimbursement have changed and grown over the past several decades, individual THOs have moved at different speeds to develop the infrastructure to support each step of the revenue cycle. Some organizations have moved quickly to adopt policies and procedures to ensure a strong revenue cycle and others have struggled to build, maintain, and grow their capabilities. When organizations have strong systems to bill, track, and receive revenue, that revenue can be used to support client care and program development for people living in the community and region.

The ATHS recognizes the need to improve financial operating systems. Strengthening financial stability and increasing the capacity for sustainable growth are two of the ATHS’s strategies for achieving its vision of healthy Alaska Native people. Building and reinforcing tribal revenue cycle infrastructures is a necessary part of increasing THO third-party revenues and achieving financial stability.

It is important to be familiar with the services you are permitted to provide and to ensure that the billing code accurately reflects the service you provided. When you complete your billing sheet, review the service code definitionsand keep in mind that:

• Each service has a specific definition; be sure you are providing the service within the parameters for the service definition.
• Services provided by healthcare providers are categorized for reporting to government or billing third-party payers (insurance companies).
• There are several different code sets that can be assigned to services you provide.
• Understanding what the codes are used for can help improve your documentation.

Code SetName	Information
ICD 9 CM and ICD 10 CM	International Classification of Diseases, 9th and 10th Revisions - Clinical Modification Classifies diagnoses, diseases, signs, symptoms, abnormal findings, complaints, and causes of injury or disease. ICD codes are generally used in medical offices.
CPT	Current Procedural Terminology Describes services provided, including medical, surgical, and diagnostic. Maintained by the American Medical Association.
HCPCS	Healthcare Common Procedure Coding System Categorizes supplies and services. “HCPCS” is pronounced “Hicpicks.”
DSM-5	Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition Establishes clinical categories for diagnostic and billing purposes. Unique code for mental health diagnoses. Published by the American Psychiatric Association.
DC-03R	Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood in Assessment and Treatment Planning Assessment tool for classifying childhood mental health. Allows for a diagnostic process that is continuous rather than rigid. Created as a way to meet the diagnostic needs of infants, toddlers, and young children. Crosswalks link DC-03 codes with DSM and ICD codes for billing.
ASAM	American Society of Addiction Medicine Patient Placement Criteria (PCC) Coding criteria for determining the level of care needed for substance abuse treatment. Mechanism for providing recommendations for level of substance abuse treatment, including prevention, early intervention, outpatient, and residential. See Chapter C-4: BHA/P Services and Common Interventions for more information. Helps with making decisions about continued services or discharge. Includes six dimensions for classifying clients: Dimension 1: Acute Intoxication/Withdrawal Potential Dimension 2: Biomedical Conditions and Complications Dimension 3: Emotional/Behavioral/Cognitive Conditions and Complications Dimension 4: Readiness to Change Dimension 5: Relapse/Continued Use/Continued Problem Potential Dimension 6: Recovery Environment
BHA SPA codes and diagnosis	Codes that certified BHA/Ps can provide under an approved State Plan Amendment (SPA). BHA/Ps can use Z-codes, DSM diagnosis, or ICD codes to summarize the client's presenting problems or behavioral health diagnosis on the billing claim.