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

Healthy Start Coding & Risk Appropriate Care

MELVIN HERNANDEZ, BA, CLSSYB QUALITY ASSURANCE & IMPROVEMENT SPECIALIST

ARIEL MOREL, BA, MS, CLSSYB, CPST DIRECTOR OF QUALITY ASSURANCE & QUALITY IMPROVEMENT

PRESENTED BY:

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

Non -DOH Entities

• Non CHD providers
• Program

Component

• 26 Prenatal
• 30 Infant

DOH Entities

• CHD providers
• CHD sub-

contractors

• Program

Component

• 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 1st attempt must occur within 5 working days of receipt of screen 2nd attempt must occur within 10 working days

• f 1st 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)
• 3rd attempt to contact must 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

• ngoing 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

• nce

Ongoing Care Coordination

Attempt to Contact (3303)

• document an unsuccessful attempt to provide a care

coordination service

• Must make three (3) attempts to contact
• Letter
• Telephone
• Face-to-face (at least one attempt)
• Unsuccessful attempt to reschedule the Initial Assessment (by

phone)

• May close after three (3) unsuccessful attempts
• 3314 (Unable to Locate)

Ongoing Care Coordination Decision Point

Care Coordination Face-to Face (3320)

• Used when CC activity is provided face-to-face
• Code when providing FSP to level 2 clients

Care Coordination Tracking (3321)

• Used when tracking activities are face-to-face or not, or when providing
• ngoing CC that is non face-to-face

Initial Family Support Plan Meeting (FSP) (3322)

• Used at the time FSP is written
• Must be face-to-face
• Code for level three participants only

Update Family Support Plan (3323)

• Used when FSP updated
• Code for level three participants only

Ongoing Care Coordination

Ineligible for Care Coordination Service (3315)

• When a mother has completed her

postpartum and family planning appointment or 8 weeks after delivery

• When a child reaches three years of age
• Completed 3 years post delivery in

program component 22 or 32

• When a participant moves out of state

Ongoing Care Coordination

Decline Services (3310) No Further Services Needed (3311) Receiving or will receive Care Coordination from CMS/EIP (3312) Receiving or will receive Care Coordination from non CMS/EIP (3313) Unable to Locate (3314) Determination for use of these codes are the same as in the Initial Contact and Initial Assessment phases, only they are decided during the Ongoing Care Coordination phase of care

Healthy Start Coding

Transition from Prenatal to Interconception

• Service Code 3324
• Used when, at the end of the prenatal period, it is

determined by the Care Coordinator that the participant still needs Healthy Start services beyond the 8 week postpartum period, but there is no infant to code service to.

• Code only one service unit to this code and any additional

time spent providing the transition to 3320 Care Coordination Face-to-Face or 3321 Care Coordination Tracking.

Other Healthy Start Services

Nutrition Assessment/Counseling (4501) Psychosocial Counseling (8002) Parenting Support and Education (8004) Childbirth Education (8006) Breastfeeding Education and Support (8008) Tobacco Cessation Counseling (8026) Interconceptional Counseling and Education (8013) All providers of these services must meet the minimum criteria outlined in the Healthy Start Standards and Guidelines

Program Components for the Healthy Start Interconception Woman

Non-CHD –Program Component 22 CHD---Program Component 32 These program components are component code are used for all Healthy Start care coordination and Healthy Start services provided to a woman between pregnancies (interconception) who is beyond the 8 week post-delivery period included in the prenatal program component or has entered Healthy Start after a pregnancy loss (described in detail below). Definition of a Healthy Start interconception woman : The woman has had a miscarriage, fetal death, infant death or has an infant who was adopted or removed from the home. This woman does not have an infant to open up as a Healthy Start participant (and provide services to on behalf of the infant) and does have risk factors that may lead to a poor pregnancy outcome. Women are eligible for Healthy Start services during the interconception period up to three years post delivery.

Healthy Start Interconception Care

May provide participants, as appropriate, with any and all Healthy Start services. Women may be eligible for Healthy Start services during the interconception period for up to three years postpartum. The definition of Interconception Care will be universal in Chapters 4, 14, and 21.

And We Are Done…

Recap Review Key Points Questions from the field

________________________________________

Contact Information: Quality Assurance & Quality Improvement Department ________________________________________

7205 N.W. 19th Street Suite 500 Miami, FL 33126 Phone: (305) 541-0210 Fax: (305) 541-0213

www.hscmd.org