Billing Manual for Community Care Network Providers

Medication(s) that have been prescribed, dosages of each medication and the datesof initial prescription and of any changes in medication regimen.Current version of DSM diagnosis on all five axes (I, II, III, IV, and V) is documented.Complete developmental history is documented for children and adolescents.The following are documented:• Symptoms• Mental status• Member strengths and limitations• Compliance with treatment plan• Compliance with medication regimen, if appropriate• If the member has drug and alcohol issues (past and/or present), the results ofthe provider's inquiry as to the welfare of children and significant others living inthe home• Progress towards treatment goals• Coordination of care information, as applicable• Date of next session• Discharge planCommunity Care expects providers to maintain an organized treatment record keepingsystem. The following elements are required components of an organized recordkeeping system.A unique treatment record for each member.Treatment record notes maintained in chronological or reverse chronological order.An organized system for maintaining documents for each member; for example, alldiagnostic reports maintained together in a section of the folder.An organized filing system that provides easy access to unique member files.Consent to release information and informed consent documentation as appropriate.Treatment record documentation occurs as soon as possible after the encounterwith special status situations, such as imminent harm, suicidal ideation, orelopement potential prominently noted.Community Care expects all practitioners and facilities to provide treatment to membersin a safe environment. All providers should assess a member for suicidal ideation andhomicidal ideation throughout a member’s treatment. If a member is being treated in anoutpatient setting and expresses suicidal or homicidal ideation, the provider should takethe appropriate actions to ensure that the member and others are safe, such asfacilitating an inpatient hospitalization admission.Upon admission for an inpatient psychiatric hospitalization, the initial evaluationcompleted by the facility psychiatrist should clearly document that the member wasassessed for both suicidal and homicidal ideation. Additionally, members should beassessed for suicidal and homicidal ideation on an ongoing basis to ensure themember’s safety, as well as the safety of others. Providers should also proceed with aDuty to Warn if indicated.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 78