INITIAL COMPREHENSIVE EVALUATION
The Initial Comprehensive Evaluation is performed during the CSHCS client’s first visit to the CMDS clinic. The medical team integrates assessments and recommendations and works with the family/beneficiary in the development of a coordinated and comprehensive POC and treatment for the beneficiary. The CMDS POC is required to be recorded. The CMDS clinic will communicate the written CMDS POC to the appropriate health care providers and the family/beneficiary. Written CMDS POCs may be provided to other appropriate health care providers for whom the parent/guardian/beneficiary has signed a medical release form. A copy of the CMDS POC is to be submitted to CSHCS medical consultants for review.
An Initial Comprehensive Evaluation visit must include the following:
* Physician specialist(s) and non-physician professionals examination or assessment of the beneficiary and submission of an established/confirmed diagnosis(es), identification of strengths and needs and, with family/beneficiary input, development of a course of action or plan for treatment;
* Integration of findings and recommendations at team conferences;
* Discussion of the medical findings and treatment recommendations with family/beneficiary in language the family/beneficiary can comprehend;
* Designation of identified staff to teach the family/beneficiary how to assist in the management of the beneficiary’s health problems if appropriate; and
* Compilation of an integrated CMDS POC from the findings of the various health care providers that includes:
* relevant history;
* medical findings by specialty;
* problem areas that may develop and for which the beneficiary should receive care;
* recommendations and prescriptions for braces, shoes, special equipment, medications, etc.;
* referral to physical therapy, speech-language therapy, occupational therapy, public health nurse, CMDS support services; and
* a description of how the CMDS POC will be implemented. Authorization and processes may differ per health plans and Fee-for-Service (FFS).
Reimbursement for the Initial Comprehensive Evaluation fee occurs only once per beneficiary per lifetime regardless of the number of diagnoses and/or CMDS clinics from which the beneficiary may be receiving services. Medical services continue to be billed as usual.
BASIC AND ONGOING COMPREHENSIVE EVALUATION
Basic and ongoing comprehensive evaluation is conducted with established CMDS patients. The evaluation(s) may include the entire CMDS clinic staff composition or asdeemed appropriate by each CMDS clinic Medical Director per visit and is documented in the CMDS POC.
A basic and ongoing comprehensive evaluation may include the following activities:
* Comprehensive beneficiary assessment;
* Evaluation and identification of the beneficiary’s needs;
* Coordination of the beneficiary’s multi-disciplinary needs;
* Review and modification of the comprehensive CMDS POC;
* Assured implementation and follow-up; and
* Referrals to other professionals, resources, and services as applicable.
Reimbursement for the Basic and Ongoing Comprehensive Evaluation fee is provided for a maximum of three (3) visits per beneficiary, per 12-month CSHCS eligibility year regardless of the number of diagnoses or CMDS clinics the beneficiary may have.
Medical services continue to be billed as usual.
MANAGEMENT/FOLLOW-UP VISITS
Management/follow-up visits to a CMDS clinic may be provided if they are recommended in the CMDS POC. In addition, a referral may be recommended based on a tertiary hospital inpatient discharge plan that was written within the previous 12 months of the referral. Every effort should be made to include all staff identified as participants in theCMDS POC or as recommended by the CMDS clinic Medical Director.
The management/follow-up visit may include:
* A physical exam by a pediatrician and/or physician subspecialist(s);
* Assessment by at least two of the clinic staff (in addition to the clinic physicians) designated for the clinic type;
* Follow-up on all components identified in the CMDS POC by appropriate staff;
* Update of condition and treatment, and revision of the CMDS POC; and
* Communication with the family/beneficiary, other providers, and other designated health care providers, including provision of copies of the CMDS POC to the family/beneficiary.
Reimbursement for the management/follow-up visit clinic fee is provided for a maximum of three (3) visits per beneficiary, per 12-month CSHCS eligibility year, regardless of the number of diagnoses or CMDS clinics the beneficiary may have. Medical services continue to be billed as usual.
SUPPORT SERVICE VISITS
CMDS clinics may provide support services. Services consists of counseling, specialized training, transition assistance and/or treatment. Support services must be ordered as part of the CMDS POC developed at a CMDS Clinic Initial Comprehensive Evaluation, Basic and Ongoing Comprehensive Evaluation, and/or Management/Follow-up Visit. CMDS clinic support services may be provided by any combination of one or more of the non-physician basic CMDS clinic staff to the family/beneficiary as outlined in the CMDS POC. Support services may be conducted by professional members of the team (i.e., nurses, dietitians, certified diabetes counselors, social workers or other clinical professional staff as appropriate). The presence of a physician is not required.
* The clinical encounter must be substantive with clinical information gathered, treatment recommendations provided, transition needs addressed and an update to the CMDS POC.
* The clinical content of the encounter is documented in the CMDS POC.
CMDS support service visits include and provide two different methods of delivery:
* Face-to-Face meetings between the appropriate clinic professional and thefamily/beneficiary; or
* Telephone meetings between the appropriate clinic professional and the family/beneficiary.
Reimbursement for support services clinic fees can be provided up to a maximum of ten (10) visits per beneficiary as a single method or as a combination of methods, per 12- month CSHCS eligibility year, regardless of the number of diagnoses or CMDS clinics the beneficiary may have. Medical services continue to be billed as usual.
ADDITIONAL RESPONSIBILITIES
CMDS clinics must establish and maintain an agreement with each Medicaid and MIChild Health Plan for health plan enrolled beneficiaries to ensure coordinated care planning and data sharing.
* CMDS clinics must establish a process for clinical staff to communicate with health plan staff on a regular basis to identify health plan enrollees using the CMDS clinic(s), review testing/assessment/screening results, treatment plans, CMDS POCs, and status of mutually served beneficiaries.
* CMDS clinics must collaborate with health plans on the development of referral procedures and effective means of communicating the need for beneficiary-specific referrals. For beneficiaries enrolled in a health plan, CMDS clinics must bill the Medicaid Health Plan (MHP) for medical services rendered according to the health plan billing rules.
The CMDS clinic fee is billed as a FFS claim through CHAMPS regardless of health plan status.
CMDS clinic fees must be billed according to instructions contained in the Billing & Reimbursement for Professionals Chapter of this Manual. CMDS clinics must bill clinic fees following Uniform Billing (UB) guidelines on the professional CMS-1500 claim format or the electronic Health Care Claim Professional (837) ASC X12N version 5010 information. CHAMPS NPI claim editing will be applied to the billing, rendering, supervising, attending, servicing and referring providers as applicable for payment.
Explanation of Services
In addition to medical services, the CMDS Clinics provide:
• A single place and extended appointment for the family to be seen by their team of pediatric specialty providers as well other appropriate health care professionals during that one appointment;
• An environment where the providers come to the family for the single appointment at the clinic as opposed to the family needing to set separate dates and times to go to each provider as in the usual service methodology;
• Same day, face-to-face care coordination by all of the providers who have seen the beneficiary at that appointment allows for immediate discussion, negotiation, coordination and duty assignment of the decisions made that resulted from the provider meeting that follows the appointment. The family does not need to interpret information from one provider to the next which risks misunderstanding as in the usual
service methodology;
• Development and upkeep of a coordinated and comprehensive plan of care and treatment for beneficiaries including clear statements of current comprehensive assessment and ongoing treatment plans available to the entire team;
• Facilities that are tailored to the needs of children and their families; and
• Opportunity for the parent/beneficiary to participate in treatment planning, allowing for timely feedback and discussion of concerns with specialists and other health care professionals simultaneously when needed.
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