Kaiser

The Initial Evaluation BPS Kaiser (Initial Intake session) note is used the first session for every new Kaiser patient.  Clinicians are required to complete an Initial Evaluation BPS in Lucet and Initial Evaluation BPS Kaiser note in Tebra.  The note in Tebra is shorter and is mainly used for billing, creating SMART goals and noting the Lucet BPS was uploaded to the patient's chart.

*Completing a Biopsychosocial (BPS) intake is the first session to be provided unless clinically indicated (patient is in crisis etc.) so that the provider can gain background and history on a patient in order to create SMART Goals.  If a clinician was unable to complete a BPS, then the session will turn into a 90837 Individual Session and the clinician will fill out a Progress Note instead. Then the following session with the patient will be the Intake Session and the BPS will be completed at that time. However, the BPS is usually able to be completed by the first session. 

Progress Notes are used every time after the Initial BPS Kaiser Note until the patient is discharged and the Discharge note is completed.  

For Kaiser patients it is required to schedule one hour blocks to complete either an Initial Intake-90791 or a Progress session-90837. If the clinician is only able to have a session with the patient between 38-52 minutes then the session is considered a Half Session-90834. The clinician would use a Progress note in Tebra for documentation for this but would use the CPT code 90834 instead. 

The 90847 code be used for family/couples sessions when the treatment unit referral is the family or couple. There will be an individual patient within this family/couples treatment unit who is financially responsible for the treatment by going through either their insurance or paying by cash. A signed release of information must be signed by the individual patient and all persons participating in treatment before the first session begins. Family/couples sessions can also be conducted when it is clinically indicated for one of your individual patient's you are seeing for individual therapy would need to include a 3rd party person(s) whether it is a family member, partner, friend, etc. The family/couples must be referred to as the entire treatment unit.

When it is clinically indicated to have a family or partner join an individual session then this is considered an individual collateral (conjoint) session because the family members or partner have joined and in your progress note you document this information. Also, in an individual collateral session, the patient is your patient and you will be meeting the goals of your patient with the family members or partner attending the session. The family members and partner are not your patient so always let them know that you are not their therapist and that they are attending these sessions to help meet the patients goals. Also, it is important to have your patient sign a release of information form when other people attend their therapy sessions.

If your patient would like family or couples therapy sessions additionally and it is clinically indicated then these sessions are 30 minutes in length and you would use the 90847 code.

The family or partner and your patient are considered to be the unit in treatment for therapy. However, one person who is usually your patient or could be someone else in the unit is the person that the insurance goes through and notes are completed under.

A individual 90837 and 90834 patient session can be used as a collateral/conjoint session when the treatment unit referral is the individual patient and the 3rd party person(s) are added into the session in order to help meet the patient's treatment goals. A signed release of information must be signed by the patient and all persons participating in treatment before the first session.

A Discharge Summary needs to be completed for every patient that is no longer being seen. There is a Discharge Note located in Lucet but to maintain our records clinicians must also fill out a Discharge Summary Kaiser note as well.  This will include downloading the Discharge note from Lucet and uploading it to the patient's chart in Tebra. 

1. Send patient email with referrals, phone numbers, resources, maintenance plan, etc.

2. Close the treatment plan 

3. Add discharge summary to Lucet and upload it to Tebra

• Call/text therapist when/if ready to resume sessions

• Call Forward Wellness or Kaiser if she would prefer a different therapist (phone numbers provided)

• If she has new insurance, Utilize Psychology Today or call insurance for new therapist (website provided)

• Utilize Ginger app and Calm app, and other grounding skills taught in sessions (download directions provided)

• Utilize social support daily

• Call National Suicide Prevention Lifeline if needed (phone number provided)

4. Add discharge summary in Tebra (12345 CPT code)

• Use most current discharge summary template

• Patient has missed at least two consecutive appointments. Therapist has been unable to contact patient for several weeks, despite multiple attempts.  Therapist does not have reason to contact patient’s emergency contact or emergency services, as patient does not have a recent history of suicidal or homicidal ideation. Therapist has emailed patient a discharge letter that included the reason for being discharged, an offer to resume services, 3 referrals, and the phone number for the National Suicide Prevention Helpline. Therapist has uploaded discharge summary from Lucet.

• Patient has determined that they would not like to continue therapy services due to _________________. Therapist encouraged patient to reach out to the therapist if patient would like to resume treatment. Therapist ensured patient had the therapist’s phone number, the Forward Wellness office phone number, the Kaiser Mental Health phone number, the Kaiser Group Therapy site, the Kaiser Webinar registration site, and the National Suicide Prevention Helpline phone number. Therapist has uploaded discharge summary from Lucet.

• Patient has determined that they would not continue therapy services due to a change of insurance. Therapist provided patient 3 referrals who take her new insurance. Therapist also provided patient and the National Suicide Prevention Helpline phone number. Therapist encouraged patient to reach out should they need further assistance. Therapist has uploaded discharge summary from Lucet.

5. Inform PCC of discharge

6.   PCC deactivates Patient’s chart

A Safety Plan is required to be completed in Lucet when the patient scores 3 or more on a Suicide Risk Screen, which you can see on the TPI that is given every session. The Safety Plan from Lucet is required to then be uploaded to the documents section of the patient's chart in Tebra.   The clinician must complete a quick "Safety Plan Kaiser" note to show there was a Safety Plan uploaded to Tebra.

If a patient scores 3 or more on a Suicide Risk Screen the clinician is required to complete a Suicide Risk Assessment - Long note. This note is a more comprehensive assessment for evaluating suicide risk.  The note includes a standard Columbia Suicide Risk screen as well as other factors to have a more rounded understanding of patient's risks. 

An assessment (TPI) that is sent out at the beginning of every patient session. After the patient completes the TPI the clinician will go over the score with the patient and process whether or not there is or is not progress. It is during this process that the clinician will inform the patient of any necessary "next steps", such as a safety, etc.

Kaiser only allows for one TPI to be completed one time a week. A clinician may send the TPI as many times as needed for the patient to complete.  However, once a patient has completed one for that week, the clinician will be unable to send and have the patient complete another.  Lucet explained that if a provider tries to send a TPI after one has been completed within the same week, they will get a pop up message to notify the provider that a patient has already completed the TPI for the week.

It is encouraged to have the TPI completed every session, but understand that may not be possible on occasion based on a recent change.  The hope is that if the patient completed the TPI if there was additional session earlier in the week, the provider is still reviewing that information and discussing it with the patient,  although it was not the exact TPI for that session. 

The TPI is a requirement for Kaiser. If a patient does not want to fill out their TPI you can offer them to not go through Kaiser Insurance and pay out of pocket. 

*It is suggested the clinician sends the TPI screen to the patient when the session has begun within the first few minutes of the session. This ensures that the patient has received the TPI and can complete it without it needing to be resent because it will time out and not be able to be resent. The TPI is a part of the therapy session and once it has been completed then the clinician continues with the therapy session. The TPI must be completed every session. However, if the patient is resistant to complete the TPI then the clinician can discuss this with the patient and let them know that the clinician can fill out the TPI for the patient and ask the necessary questions for them if they cannot complete the TPI out themselves. The clinician can navigate to ‘Add Assessment’ then Select View ‘Launch Onsite for Patient’ to fill the TPI out for the patient as the patient answers the questions.

For cancellations made less than 24 hours (unless due to illness or an emergency) or a scheduled appointment that is completely missed and not rescheduled, the patient will be charged a $60 late cancellation fee. 

• • This policy above should be added to your Lucet Profile settings as well. 

Clinical Reviews for Kaiser Patients: There is no form for this. However, in regards to completing a clinical review, or other consultation requests or questions, the KPEP team may request a clinical review one time a year (completed in Lucet under Notes in the patient’s profile) for additional information. 

Clinicians and coordinators need to review the Documents section in Tebra and make sure that all intake documents and screen assessments have been filled out and signed by the patient before the session is conducted. If the Intake Documents have not been submitted by the patient, then the Clinician must ensure that each intake documents are in the Documents section in Tebra, by either collecting the documents from the patient themselves or partnering with a coordinator.  These documents include but are not limited to:

• Informed Consent (patients are required to resign a new Informed Consent 1 time a year, sent by clinicians)

• Patient's ID

• Insurance card (front and back) 

• Initial Discharge Plan Resources

• Kaiser Consent for Release of Information (for Kaiser patients)

800-350-3207 - Clinicians can send this number to Kaiser patients for additional support and resources. 

Kaiser patients can call the KP Behavioral Healthcare Line at 800-900-3277 and request free 1 year access to the Calm app.

There is a Release of Information note available in Tebra to be customized at any time.  There is a requirement to have an ROI signed by patients in order to see any Kaiser patient.  It is also legally required for the patient to fill out an ROI in order to have a collateral session. 

To create an additional Release of Information:

1. Open a Release of Information note in Tebra: "ROI"

2. Click in the Release of Information section to reveal the "Template" button

3. Select the most recent ROI Template

4. Check off all the items with an asterisk (*) to ensure you have all the items included on the ROI note when the template populates

5. If one of the items on in the template list opens another menu, add in the appropriate information

6. Select the "Close" button on the template to populate the information into the note

7. Read the information populated and fill in all asterisked items: Clinician contact name, Clinician contact number, Clinician email, Name of person and/or agency to release or obtain information from, etc

8. Read the "Filing and Instructions for Staff" section on the bottom

9. Save and sign the note

10. Open the Release of Information note again (if you sign a note in Tebra, it will automatically close the note so you have to reopen it again)

11. Superbill or Capture Charge for the note: include the CPT code "00000 Release of Information"

12. Select the "Send to Billing" or "Submit to Biller" button

13. Select the "Actions" button on the upper right of the screen and select "Print" 

14. Download the document to your computer

15. Email the document to the patient for them to sign and email back to you

16. Once the patient signs the document and returns it to you, then upload the document into the "Documents" section of the patient's Tebra chart

17. Make a freeform note in Tebra called "Memo to Record" or update the patient's "Progress Note" to document that the Release of Information was completed