Care Coordination Documentation



NOTE: Your legal consul should be consulted prior to implementation of this policy.

Purpose: Care Coordination records are maintained

• To ensure a complete and accurate care coordination record that is recipient-specific and facilitates ongoing care coordination of the recipient’s waiver services.

• To demonstrate compliance with all federal and state laws as they apply to providing health care or related services to Medicaid recipients in this state, including laws related to recipient confidentiality, electronic transactions, and civil rights

• To support decisions and guide care planning.

• To facilitate performance improvement.

• To serve as a legal record that supports billing for services rendered.

• To define the records retention policy of the care coordination agency.

• To describe the documents that comprises a complete recipient record.

Policy: Recipient records are maintained in accordance with 7 AAC 105.230 Requirements for Provider Records, 7 AAC 105.220 Provider Responsibilities and federal requirements. In addition these records and their management will adhere to this care coordination agency's following procedures.

Procedure:

Progress Note Documentation: The Progress Note form contains supporting documentation of the agencies billing for care coordination services. In addition the Progress Note documents the agency's ongoing monitoring of the recipient and the Plan of Care. The Progress Notes also include a satisfaction survey for services received.

Each recipient has a unique file as specified in the Recipient record contents below. That file is the location for all Progress Notes and Billing documentation. A separate Progress Note is started for each monthly service provided.

The monthly face-to-face visit contains a review of the recipient's current status that would include any changes in condition, new diagnosis, and medication changes from those documented in the assessment. Next a review of the services in the Plan of Care is conducted. This review includes whether the services are provided as specified in the Plan of Care and the recipient's progress in meeting the expected outcomes identified in the Plan of Care.

Any additional observations or concerns from the recipient are documented in the progress notes on the second page.

All entries into the record are date, timed and signed by the person providing the service.

Additional recipient contact section allows for the documentation of telephonic contacts with the recipient or their legal representative during the course of the month. Those contacts are dated as they occur. There are additional areas to document contacts with family members, providers or other interested parties. Progress notes on page two that may be used if more space is required or to document the date of completion of a Plan of Care or Amendment that is sent to Senior and Disabilities Services (SDS).

Satisfaction survey allows for an evaluation of recipient satisfaction with services provided in the Plan of Care. Of particular concern are those complaints that pertain to health, welfare and safety issues as well as abuse, neglect financial exploitation. Those issues are referred to SDS Quality Assurance (QA) Unit or Adult Protective Services (APS).

The recipient or their legal representative signs the Progress Note at the face-to-face visit.

Billing Documentation: Billing is supported by the Care Coordination Agency Progress Notes.

Dates of service: may be the dates in the month being billed for ongoing care coordination or the date the Screening, Plan of Care or an Amendment was completed and sent to DSDS Program Staff.

Code: refers to the procedure code for the specific care coordination service being billed.

Description: in care coordination is Screening, Plan of Care, Amendment or Ongoing Care Coordination.

Charge: refers to the actual authorized cost of the service. This is the amount billed to Medicaid.

Payment Sources: refer to the entities billed for the services.

• Some recipients in an agency may be billed as private pay clients. This column may be used to document Cost of Care payment billed to a recipient's Medicaid qualifying trust.

• The primary source is usually an insurance entity.

• The secondary or last payer is Medicaid.

• Note 1: when a Medicaid Cost of Care is billed to the recipient include that payment amount in the billing. Bill the full authorized amount for the service and annotate the Cost of Care payment in block 29 of the paper billing or the amount paid block for other payment sources in electronic submissions. Medicaid will deduct the Cost of Care from the billing and pay the balance.

• Note 2: when private insurance is present bill the insurance first. If an EOB is received denying the claim, bill Medicaid for the full amount and include the EOB with the denial in the billing.

Payment received: document all payments as they are received. There maybe more than one line especially in Cost of Care instances. The recipient's trust may pay first then Medicaid would pay any remaining balances.

Internal Controls: The owner or supervising care coordinator reviews all billings to assure that there is a Care Coordination Agency Progress Note that supports the billing. In the instance of Ongoing Care Coordination, that the note meets agency standards reflecting that ongoing monitoring was conducted or that a Screening, Plan of Care or Amendment was submitted to SDS. Notes reflect that the expected outcomes were documented and that any identified health, welfare, safety or Adult Protective Services issues were appropriately documented and referred to SDS. If there are no notes that support the service provided then Medicaid is not billed.

Guidelines

• Documentation found in the recipient record must be readily accessible, accurately recorded, complete, and organized for efficient retrieval of needed data.

• Handwritten entries or signatures should be legible.

• A recipient's record must identify recipient information and include the following:

1. Recipient receiving each service provided,

2. Specific service being provided,

3. Extent of the service being provided,

4. Date (day, month, year and time) on which each service is provided and

5. Identify the individual care coordinator providing the service.

• Recipient record entries are contemporaneous (written as they occur). Entries are made when the service described is given or the observations to be documented are made, or as soon as possible thereafter.

• Handwritten or electronic signatures should contain the employee’s initial or first name, full last name, and abbreviation of licensure as appropriate.

• Abbreviations used are identified in a glossary located in the recipient record.

• Do not pre- or post-date entries (care coordination progress notes may be entered as “late entry” with an explanation.)

• Complete obliteration of any documentation is not permitted (e.g., correction fluid or correction tape).

• Standardized formats are used for documenting all care, treatment, and services provided to recipients.

• Certified and enrolled care coordinators of the agency make entries in recipient records. A back up care coordinator is identified in the recipient's record as per the care coordination manual and may make entries in a recipient record in the absence of the care coordinator of record.

Recipient Record Contents

A complete recipient record consists, at a minimum, a record of therapeutic services, according to professional standards applicable to the care coordination, applicable state and federal law, the applicable Alaska Medicaid Provider Billing Manual and all updates, and any pertinent contracts. The clinical record maintained by the agency must have clinical information to:

(1) identify the recipient's diagnosis;

(2) identify the medical need for each service;

(3) identify each service, prescription, supply, or approved plan of care prescribed by the provider, if applicable; and

(4) include annotated case notes, signed, dated, or initialed by the individual who provided the service, for each service delivered.

• Screening Form - documentation of the approval of the screening and issuance of the Care Coordination Assignment Number is attached to the screening form.

• All Legal Documentation - this includes but is not limited to:

1. Client Choice of Services,

2. All Releases of Information,

3. Advanced Directives,

4. Powers of Attorney,

5. Guardianship, an/or

6. Conservatorship court orders,

7. Documentation of care coordination transfers and

8. Environmental Modification Consents.

• All Assessment Documents - include documentation of the approval of the level of care.

• All Plans of Care - with documentation of approval.

• All Other Health related Correspondence including Physician Orders

1. Diagnostic and therapeutic orders

2. Medication orders with accompanying diagnoses and/or indications for use, strength, dose, frequency, and route of administration.

• HIPAA Notices - and documentation of Receipt of Privacy Notice and a record of all disclosures of information.

• Recipient’s Rights - with documented evidence of recipient's or recipient’s representative receiving a copy of recipient rights.

• Care Coordination Case Notes.

• Records of all billings.

Other Documents:

• Identification - of the state and Federal law and regulations relevant to the services delivered to the recipient.

• Correspondence - with Division of Senior and Disabilities Services.

• Correspondence - with Division of Public Assistance.

• Correspondence - with providers of recipient's services.

• Correspondence - with family, legal representatives, friends or other interested parties.

Financial Records - the financial record must identify the following financial information:

• The date of service and the charge for each service provided,

• Each payment source pursued including Cost of Care payments,

• The date and amount of all debit and credit billing actions for each date of service provided'

• The amounts billed and paid.

Records Retention:

• All provider records are maintained for a period of seven (7) years from the date the service is provided.

• Records may be maintained in electronic format. Those records must be readily available upon request.

• When updating software keep the software being replaced with the CD's that were created by that software.

• All records destruction must cease when notified of a state or federal audit or investigation.

Satisfaction Survey:

• Each month the recipient survey findings are collated.

• Document the findings of each survey.

• Document efforts at correction of findings.

• Report negative findings and corrective actions to DSDS QA Unit.

CARE COORDINATION AGENCY PROGRESS NOTES

|Date Time |Notes |

| |Current status: (document any changes in condition or medications.) |

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|SERVICES PROVIDED |Comments | |

|Chore Services | | |

|Respite Services | | |

|Adult Day Care | | |

|Assisted Living Services | | |

|Spec. Pvt Duty Nursing Svs | | |

|Transportation Services | | |

|Meal Services | | |

|Special Equipment/Supplies | | |

|Physician Visits | | |

|PCA Services | | |

|Hosp. Since last visit? | | |

|Other: | | |

Additional Recipient Contacts:

|Date Time |Nature of contact: |

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|Date Time |Nature of contact: |

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Additional Family/Provider/Other involved individual contacts:

|Date Time |Nature of contact: |

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|Date Time |Nature of contact: |

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Additional notes may be transcribed on the back of the form.

Provider Name _____________________ Signature_____________________ CM # ________

Recipient Signature: ______________________________

(For face-to-face visit only)

|DATE |PROGRESS NOTES |

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Consumer Satisfaction Survey

1. Are you satisfied with the quality of the services you receive? Yes No

If not, what service are you dissatisfied with? _________________________

Who is the provider? _____________________

How would you like this situation corrected?

2. Are there any other services or changes to your Plan of Care that you need? Yes No

What changes are needed?

What is the reason for these changes?

1. How is your living situation?

2. Is there a need for any referrals? Yes No Describe who the referral is for and the reason.

INSTRUCTIONS

CARE COORDINATION AGENCY PROGRESS NOTES

|Date Time |Notes |

|Of the face-to-face visit. |Current status: (document any changes in condition or medications.) |

| |Have there been any changes in diagnosis or Medications? |

| |Are there in changes is cognition? |

| |Are there any changes in functional abilities? |

|SERVICES PROVIDED |Comments | |

|Chore Services |Were services provided? Is the residence clean and safe? | |

|Respite Services |Were services provided? | |

|Adult Day Care |Were services provided? | |

|Assisted Living Services |Were services provided as specified in the assisted living supplement of the Plan of Care? | |

|Spec. Pvt Duty Nursing Svs |Were services provided? | |

|Transportation Services |Were services provided? | |

|Meal Services |Were services provided? | |

|Special Equipment/Supplies |Were services provided? | |

|Habilitation (Specify) |Were services provided as specified in the Habilitation Plan? Are the goals being addressed | | |

|PCA Services |Were services provided? | |

|Physician Visits |What was the reason and outcomes of the visit? | |

|Hosp. Since last visit?Other: | | |

Additional Recipient Contacts:

|Date Time |Nature of contact: Specify type of contact. |

| |Can be the second monthly contact via phone or in person. |

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|Date Time |Nature of contact: |

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Additional Family/Provider/Other involved individual contacts:

|Date Time |Nature of contact: |

| |May be contacts with family (if recipient has given approval for contact). |

| |May use for contacts with providers in the coordination of services. |

|Date Time |Nature of contact: |

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Additional notes may be transcribed on the back of the form.

Provider Name _____________________ Signature_____________________ CM # ________

Recipient Signature: ______________________________

(For face-to-face visit only)

|DATE |PROGRESS NOTES |

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Consumer Satisfaction Survey

1. Are you satisfied with the quality of the services you receive? Yes No

If not, what service are you dissatisfied with? _________________________

Who is the provider? _____________________

How would you like this situation corrected?

2. Are there any other services or changes to your Plan of Care that you need? Yes No

• What changes are needed?

• What is the reason for these changes?

3. How is your living situation?

4. Is there a need for any referrals? Yes No Describe who the referral is for and the reason.

Note: Referrals my mean reports to Adult Protective Services, Child Protective Services or DSDS QA. This area may also address needs for an amendment to the Plan of Care.

This could also be a referral to Podiatry Services for a Diabetic.

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