Additional documentation
The first commandment of documentation is that documentation is a basic element of case management services. It is not an add-on; it is not optional; it is not separate from service provision; and it is not just paperwork.
Recommendation: To obtain the monthly adult MH-TCM reimbursement, as least one of the four core component services must be documented as having been provided during a face-to-face contact with the client (or during a qualifying phone contact with the client). Use the core service terminology: document that you, the case manager, were assessing, planning, referring and linking, and/or monitoring and coordinating with the client present. Provide other details and be sure that the contact documentation is directly connected to at least one of the goals/objectives in the ICSP. Don’t document billable service contacts with the client that do not clearly specify which qualifying services were provided. Example: Don’t write gave a ride to the client to the social security office. Instead, write Per ICSP, client was accompanied for needed support to the SS office. Task was referral and linkage to help gain access to SSD……