Medical necessity and person centered planning

MEDICAL NECESSITY
1
NANCY DURLIN, MSW, LCSW
PROGRAM SPECIALIST II
ADA/CPS BILLING AND SERVICES REVIEW TEAM
FULTON STATE HOSPITAL, 600 E. 5TH ST.,
MS #600
FULTON, MISSOURI 65251
573-592-2102 FAX: 573-592-2095
NANCY.DURLIN@DMH.MO.GOV

MENTAL ILLNESS
2
Mental illness is a medical
condition.

REVIEW PROCESS
3
When reviewing documentation to
determine whether the services provided are
medically necessary, we look to the
assessment to confirm eligibility for the level
of services being provided, and the
identification of functional deficits and
needs. Once we are assured that the person
being served is eligible, we look at the
person’s stated preferences, strengths,
assets, challenges and resources.

INDIVIDUAL TREATMENT PLAN
The person receiving services participates in
the development of their individual
treatment plan, integrating their hopes and
dreams into the outcomes/goals.
Assets are identified.
Obstacles are identified.
Resources are identified.
4

SPECIFIC VERSUS GENERIC
The assets, obstacles and resources are not
generic, but are person and outcome
specific. A different description of assets,
obstacles and resources may relate to each
outcome on the treatment plan; however,
several may be more global and relate to
several or all outcomes.
5

ITP Objectives
Objectives are person-centered and measurable.
6

INTERVENTIONS
Interventions are descriptive of supports that
will be provided, including frequency,
duration, target dates and the title of
persons who may provide the supports.
Interventions should relate back to the
needs identified on the assessment.
7

ITP REVIEWS
Reviews are performed at regular intervals,
including ITP changes which support the
individual’s progress in recovery.
8

Service Plans- Common Mistakes
• Person served does not appear to be involved in the
plan or process
• Outcomes/Goals are not recovery oriented
• No person-first language
• Generic assets/strengths: non-specific to goals,
objectives & interventions
• Generic goals & objectives: not individualized to
person being served
• Goals & objectives in clinical language/terms which
are generic and meaningless to the person being
served
9

PROGRESS NOTES
All services provided by an agency should be recorded
in the medical record, whether they are billable or
not.
Progress notes report services provided, as prescribed
by the ITP, and address needs identified in the
assessment.
10

LACKS MEDICAL NECESSITY
Examples of documentation that lack medical necessity: (the
missing piece)
The amount of time billed for a service or intervention is in excess of a
range of what would be expected based upon the treatment plan,
evaluation or other documentation.
11
The assessment or evaluation may not have identified a need for service
(s)
Providing service that appears routine, random, unplanned, or
unnecessary
Providing service simply because the person served requested
Service provided is not within standard or accepted practice guidelines
and lacks clinical justification or approved exception
Service lacked clinical justification of need

THE GOLDEN THREAD
12
Ensure that Medical Necessity pieces fit -- Clear
identification and association between the deficits/
needs in assessment, service plan, and progress
notes.