Healthy Start Coding & Risk Appropriate Care PRESENTED BY: - PowerPoint PPT Presentation

Healthy Start Coding & Risk Appropriate Care PRESENTED BY: MELVIN HERNANDEZ, BA, CLSSYB QUALITY ASSURANCE & IMPROVEMENT SPECIALIST ARIEL MOREL, BA, MS, CLSSYB, CPST DIRECTOR OF QUALITY ASSURANCE & QUALITY IMPROVEMENT

Training Objectives Define Risk Appropriate Care ◦ Classify each level of care ◦ Determine individual’s level of care Understand Healthy Start Coding ◦ Explain the importance of coding ◦ Define each code ◦ Determine when to utilize each code

Training Outline  Risk Appropriate Care  The Purpose of Healthy Start Coding  The Healthy Start Encounter Form  Healthy Start Service Codes

Risk Appropriate Care

Risk Appropriate Care  Care and services designed and individualized to the participants risks, strengths, and needs  Should provide appropriate interventions necessary to modify risk factors

Risk Appropriate Care  What is a risk factor?  Something that increases a person’s risk for having a poor health outcome ◦ Smoking ◦ Poor access to healthcare ◦ Education level ◦ Race/ethnicity

Risk Appropriate Care  Healthy Start Levels  Used to determine the intensity and duration of services determined by the Healthy Start Care Coordinator for the participant. ◦ Level P: pending initial contact ◦ Level E: require only the service components of an initial contact and closure ◦ Level 1: inadequate knowledge about resources and needs short term follow-up, *after three months participant must be moved to another level or closed ◦ Level 2: inadequate knowledge about resource needs and require moderate follow-up, *can have a family support plan completed but not coded ◦ Level 3: safety concerns and a need for crisis intervention and intensive services *face to face contact and family support plan coded Proper coding details whether a client is receiving the appropriate level of care based on their level

The Purpose of Healthy Start Coding

What is the purpose of Healthy Start coding?  Gives an account of all the Healthy Start services  Provides proof of services for Medicaid reimbursement  Generates valuable data/reports on Healthy Start’s community impact

Healthy Start Encounter Form

Encounter Form  The “Invoice” for provided Healthy Start services  Entered into HMS reporting system  Used to generate data ◦ Executive Summary Report ◦ Healthy Start Annual Report ◦ Medicaid Waiver Billing ◦ Performance Measures

Encounter Form DOH Entities Non -DOH Entities ◦ CHD providers ◦ Non CHD providers ◦ CHD sub- ◦ Program contractors Component ◦ Program ◦ 26 Prenatal Component ◦ 30 Infant ◦ 27 Prenatal ◦ 31 Infant

Encounter Form Section A ◦ Demographic Information Section B ◦ Provider Information ◦ Special 19 Group Code Section C ◦ Service Codes ◦ Initial Contact ◦ Initial Assessment ◦ Ongoing Care Coordination ◦ Other Healthy Start Services ◦ Administrative Codes

Encounter Form  Encounter Forms ◦ The Special Group Field ◦ The elimination of the encounter form terminates the need to identify the special group code each time a service is provided ◦ Utilization of the HMS requires that this information be entered once

Healthy Start Service Codes  Initial Contact  Initial Assessment  Ongoing Care Coordination

Initial Contact (IC)  Point of entry into Healthy Start  Evaluation of service needs  1 st attempt must occur within 5 working days of receipt of screen  2 nd attempt must occur within 10 working days of 1 st attempt to contact

Initial Contact  Attempt to Contact (3103) ◦ Used to document an unsuccessful attempt to contact ◦ 3103 is the only code that can be used more than once ◦ Code at least one service unit for all attempts ◦ Must make 5 attempts to contact ◦ Letter ◦ Telephone ◦ Face-to-face (at least one attempt) ◦ 3 rd attempt to contact m ust be made within 10 working days from the second attempt to contact ◦ 2 additional attempts must be completed within required time frames or soon there after ◦ May close after 5 unsuccessful attempts ◦ 3114 (Unable to Locate) ◦ Do not use closure code 3119 (Unable to Complete IC)

Initial Contact Decision Point  Needs Tracking Only (3101) ◦ Follow –up on the client’s ability to access services ◦ Face-to-face or telephone ◦ Move to ongoing care coordination for clients who do not need an assessment within 10 working days  Participant Needs Assessment (3102) ◦ Need for face-to-face assessment ◦ Done, or attempted, within 10 working days

Healthy Start Coding  Initial Contact (IC) ◦ Participant Needs Assessment ◦ Special Note ◦ If participant needs services before completion of the Initial Assessment, the service should be provided and coded to ongoing care coordination either tracking or face-to-face

Initial Contact Closure Codes  No Further Services Needed (3111) ◦ Participant and Care Coordinator both agree no further services are needed  Receiving or will receive Care Coordination from CMS/EIP (3112) ◦ Use when care coordination is adequately provided by CMS or EIP  Receiving or will receive Care Coordination from non CMS/EIP (3113) ◦ Use when care coordination is adequately provided by a non CMS or EIP provider  Unable to Provide Completed Initial Contact (3119) ◦ The participant refuses the IC before all components of the IC have been completed ◦ Participants with score less than 4 ◦ Referred based on other factors ◦ No safety concerns ◦ No immediate needs

Initial Contact Closure Codes  Decline Services (3110) ◦ Participant verbally declines services after the initial contact has been provided ◦ Care coordinator may feel the client needs further services  Unable to Locate (3114) ◦ Initial contact has not been provided ◦ Participant covertly declines services by not responding to attempts to contact ◦ Three or more attempts must be made before closing to this code

Healthy Start Coding  Initial Contact ◦ Closure ◦ If participant that has previously been closed returns to the program during the same pregnancy or for the same infant: ◦ Codes ◦ Reopen the case using the appropriate code based on their point during care coordination at the time of closure ◦ Example: ◦ If the IC was provided then re-open the case in the IA phase if needed or move directly to care coordination

Initial Contact  Initial Contact Service Units (3115) ◦ Used to account for time spent providing an initial contact outcome beyond the one service unit for initial contact outcome ◦ Time spent providing evaluation ◦ Travel ◦ Documentation ◦ Referrals ◦ Telephone calls  Service units are coded in 15 minute blocks

Initial Assessment (IA)  Face-to-face evaluation  Done with prenatal participant and family , if desired  Done with infant participant and parent or guardian  Done within 10 working days of Initial Contact  Maybe performed in conjunction with a face-to-face Initial Contact ◦ Code both outcomes and split the time spent between both service units (3115 & 3215)

Initial Assessment  Attempt to Contact (3203) ◦ Attempt must be provided Face-to-Face ◦ Home Visit ◦ Clinic or WIC Appointment ◦ Any other location where the participant and the Care Coordinator are face- to- face ◦ Service code used is 3203  Successful calls to the participant’s healthcare provider, WIC, etc. to determine the participant’s next appointment in an attempt to meet with the participant can be coded to 3321, care coordination tracking, not face to face, as you are tracking services.  Unsuccessful Non Face-to-Face Attempts ◦ Code to Care Coordination attempt to contact, service code 3303

Initial Assessment Decision Point  Needs Tracking Only (3201) ◦ Client needs less intensive care coordination services  Plan Ongoing Care Coordination (3202) ◦ Client needs more follow-up than would be provided by tracking only  No Further Services Needed (3211) ◦ Participant and Care Coordinator both agree no further services are needed

Initial Assessment  Decline Services (3210)  No Further Services Needed (3211)  Receiving or will receive Care Coordination from CMS/EIP (3212)  Receiving or will receive Care Coordination from non CMS/EIP (3213)  Unable to Provide Completed Initial Assessment (3219)  Determination for use of these codes are the same as in the Initial Contact phase, only they are decided during the Initial Assessment phase of care

Initial Assessment  Initial Assessment ◦ Unable to Locate - 3214 ◦ The participant covertly declines services by not responding to attempts to contact; ◦ Three face-to-face attempts have been made and documented; ◦ Repeated unsuccessful attempts to reschedule the Initial Assessment

Initial Assessment  Initial Assessment Service Units (3215) ◦ Used to account for time spent providing an initial assessment outcome beyond the one service unit for initial assessment outcome ◦ Time spent providing evaluation ◦ Travel ◦ Documentation ◦ Referrals ◦ Telephone calls  Service units are coded in 15 minute blocks

Ongoing Care Coordination  Process to assist families with locating, coordinating, and monitoring needed services  Not all participants will receive ongoing care coordination  Ongoing Care Coordination codes can be used more than once  Care Coordination Closure codes can only be used once