System Maintenance - Service Codes - Cal-PM

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Manage myAvatar service codes.

Avatar PM > System Maintenance > System Definition > Service Codes

A service code is used to track billable and non-billable client or provider events.
Service codes define client treatment, room and board charges, and staff only services.
Fields enabled by registry settings.

CSI Service Code Setup

CSI Reportable Service Codes must be configured to report correctly to CSI. CSI reportable services not configured for CSI reporting will appear on the CSI Compile Error report in CSI Submission for a given compile. Each CSI service is classified as either a Mode 5 (24 Hour Service), Mode 10 (Day Service), or Mode 15 ( Outpatient Service) type of service. When defining a Mode of Service for a service code, only one Service Function (CSI Mode of Service) field needs to be defined. Service Function (CSI Mode of Service) fields available to define the CSI Mode of Service are:

Service Function (CSI - Mode 5)
Service Function (CSI - Mode 10)
Service Function (CSI - Mode 15)

Additionally the field Units of Time must be defined for the service code to allow CSI Unit/Time Calculation. This field is exclusive to CSI State Reporting Functionality. This field is solely used to calculate CSI Service Record Units of Time and does not have an impact on billing or Cal-Billing unit calculation.

Select Service Code

In the Add New or Edit Existing field:

Select Add to add a new service code.
Select Edit to edit an existing service code.

In the New Service Code field, enter the code.
In the Service Code field, enter the code, click the Search button, and select the corresponding entry.

Basic Information

In the Inactive Service Code field, select Yes to deactivate the service code. The service code will not be available in forms throughout Avatar. Inactive service codes can be reactivated in the Reactivate Service Codes section.
In the Service Code Definition field, enter the service code description.
Ampersands (&) are not permitted in this description.
In the Service Required By field:

Select Both if a staff member, and a client are required for the service. For example, a therapy session (billable service).
Select Client Only if a client is required for the service. For example, a room and board service.
Select Provider if the service is a provider only service. For example, documentation completion, or a department meeting.

In the Type of Service field:

Select Individual for services provided for a single client.
Select Group for services provided for a group of clients.

In the Service Code Category field, select whether this is a primary, add-on, or interactive complexity code.
In the Service Code Type field, select the type of code.
In the Select Add-On Service Code field, select the specific add-on service code, if applicable.
In the Select Interactive Complexity Service Code field, select the specific interactive complexity code, if applicable.
In the Type of Fee field:

Choose Fixed Fee (Per Event) for a service fee that is charged a set amount each time the service is rendered.
Choose User Defined for a service that has a fee per unit of time. The service fee is dependent on the service duration.

In the Fixed Fee Units field, enter the number of service units for a fixed fee service.
In the Minutes Per Unit field, enter the number of minutes for one unit of service (user definition service). When the service time reaches the next service unit, the service fee is increased.
In the Unit Rounding Logic (user defined services) field, choose how user defined service charges are calculated when the service time reaches the next service unit (specified in the Designated Degree Of Rounding field).

Select No Rounding to increase the service charge by the next unit of time.
Select Round Any Portion Over Each Unit to increase the service charge when the service time is any amount greater than defined.
Select Round Over 1/2 Unit to increase the service charge when the service time is over one half the amount defined.

These examples use a service with 60 minutes entered in the Minutes Per Unit field:

In the Designated Degree Of Rounding field, calculate how the service fee increases when the service time is greater then a unit (user defined services).

Values
Example
Service code rounding tables - display a breakdown of service code rounding logic.

In the Group Code field, select the group code. Group codes are used to categorize service codes.

17. In the Units of Time field, select 1 Minute Period to initiate the Minute to Unit Conversion outlined in the Short-Doyle Medi-Cal DMH and ADP Companion Guides.

Department of Mental Health Minute to Units Conversation To convert minutes to units of 15-minute increments, multiply each minute of service by 1/15 (0.066667) and round to two decimal places. Example, 10 minutes of counseling x 0.066667 = .66667 rounded to .67 units.

Department of Alcohol and Drug Programs Minute to Units Conversation NTP Group and Individual Counseling (ADP Only) – ADP approves the service in 10 minute increments. To convert minutes to units of 10-minute increments, multiply each minute of service by 1/10 (.1). Example, 120 minutes of group counseling divided by 6 members is 20 minutes per member, multiplied by .1 is 2 units (120 / 6 x 0.1 = 2 units)

The Minute to Unit Conversion will only impact Loop 2400 segment SV1 data elements SV104 (Unit or Basis for Measurement Code) and SV103 (Service Unit Count). Loop 2400 segment SV103 will default to "UN” and SV104 will be calculated by using the methodology noted above based on Mental Health or Achohol and Drug. This Minute to Unit Conversion logic will only be applied to services when:

This Minute to Unit Conversion logic will only be applied to services when:

Reported on an 837 Professional processed for a guarantor defined with the System Financial Class 3, Medi-Cal
The service program is defined as a DMH or ADP program
DMH - Program Maintenance Fields
- Substance Abuse Program (CalOMS) = No
- Mental Health Program (CSI) = Yes
ADP - Program Maintenance Fields
- Substance Abuse Program (CalOMS) = Yes
- Mental Health Program (CSI) = N

The service code is defined by the field Units of Time equal to 1 Minute Period.
There is a duration defined for the service

Any services that do not fall under the above criteria will use the myAvatar standard 837 product logic for the impacted fields.

Advanced Information

In the Covered Charge Category field, select the covered charge category. This field works with the Benefit Plan form (Covered Charge Category field), and with various myAvatar forms.
In the Is This Service A Procedure field, select Yes to identify the service as a procedure.
In the Procedure Type field, select whether the procedure is a vaccination procedure or one that uses a supply code.
In the Is This A Balance Forward Service Code field, select Yes to carry outstanding balances from another application system to myAvatar Cal-PM when the facility goes “live.”
In the Does This Code Have A Professional Component field, select Yes to define the service as a professional charge, allowing the service to print on the following bills: HCFA-1500 paper and electronic, 837 Professional electronic.
In the Other Service Code Category field, select the service code category. The other service code category works with the Roll-Up Services Definition form.
In the Is This Service A Visit field:

Select Yes define the service as a visit. When the service is rendered:
The number of available visits will be decreased (set up in the Managed Care Authorizations form, Maximum Visits field).
The number of covered visits will be decreased (Financial Eligibility forms, Maximum Covered Visits field).
Select No to define the service as a service unit. When the service is rendered:
The number of available units will be decreased (setup in the Managed Care Authorizations form, Maximum Units field).
The number of covered units will be decreased (Financial Eligibility forms, Maximum Covered Units field).

In the Apply Multiple Practitioner Calculations To This Service Using field, select:

Standard Group Calculations
- For group services rendered within a DMH Program* -
  - The service duration is calculated by adding all practitioner durations, and dividing by the number of clients in the group.
  - A minimum of two group members must be present in the group, or the service charge will be $0.
- For services rendered within an ADP Program* -
  - The number of group members must be between the defined values in the fields Minimum Group Size with ADP Programs and Maximum Group Size with ADP Programs.
  - The service duration must be a minimum of 90 minutes or the service charge will be $0.
DMH Override For Group And Individual
- For any services rendered within a DMH Program* the service duration is calculated by adding all practitioner durations, and dividing by the number of clients in the group.
ADP Override For Group
- For services rendered within an ADP Program* there are no restrictions as to how many clients in the group or duration of the service.
- For services rendered within a DMH Program* the service duration is calculated by adding all practitioner durations, and dividing by the number of clients in the group.
ADP Override For Prorated Group Calculations
- For services within an ADP program, the number of group members must be between what is defined in the fields Minimum Group Size with ADP Programs and Maximum Group Size with ADP Programs and the service duration must be at least 90 minutes (or if an override is defined in the Minimum Duration For Group Service With ADP Programs field) or the service charge will be $0. Additionally, all practitioner durations are added together and then divided by the number of clients in the group.

If Use The Medi-Cal Fee As The Usual & Customary Fee' registry setting is set to 'N' and if the guarantor liability is being calculated based on the Medi-Cal rules, only those practitioners who are marked as Medi-Cal Certified will be included in the calculations. A practitioner can be marked as Medi-Cal Certified in the Practitioner Enrollment form.

* Determination of a DMH Program vs ADP Program

The system will use the Program Maintenance settings Mental Health Program (CSI) and Substance Abuse Program (Cal-OMS) to determine if the program is a Mental Health (MH) or Alcohol and Drug (ADP) Program.
DMH Program
- Program field Mental Health Program (CSI) set to Yes and field Substance Abuse Program (Cal-OMS) set to No.
ADP Program
- Program field Substance Abuse Program (Cal-OMS) set to Yes and Mental Health Program (CSI) set to No.

The calculated units used by the above mentioned formulas will be stored in the field cal_billing_units in SYSTEM.billing_tx_history. The units in this field will appear as the reportable units within the 837 when the field Bill Cal Billing Units in Guarantors/Payors is set to Yes.

In the Minimum and Maximum Group Size with ADP Programs fields, enter the minimum and maximum group sizes for services within an ADP program when Standard Group Calculations is selected in the Apply Multiple Practitioner Calculations To This Service Using: field.
When a group size is below the minimum or above the maximum group size for a group service entered in Client Charge Input, the charge becomes a $0 charge.
In the Rounding Logic For DMH Group Services field:

Select Round to the Nearest Unit to round DMH service duration to the nearest unit.
Select Round Down to round units down.
Select No Rounding to disable rounding.

In the Minimum Duration For Group Services With ADP Programs field:

Enter the minimum duration a group service in an ADP program must have to generate a service fee.
If this field is blank a duration of 90 minutes is used.
Enter 0 to require no group service duration.

In the HCFA Type Of Service field, select the code to display in the HCFA Type of Service field on the HCFA bill.
In the Per-Diem Service Code field, select Yes to define the code as a per-diem service charge.

Mode of Service

In the Mode Of Service field, select the mode of service associated with the service code. The code for this selection populates the Mode of Service column in the ADP, or DMH Short/Doyle electronic billing file.
In the Mode of Service (MAA) field, select the mode of service associated with Medi-Cal Administrative Activity Program services (MAA).
In the Mode of Service 45 Outreach field, select the mode of service for outreach services.
In the Mode of Service 55 Medi-Cal Administration field, select the mode of service for Medi-Cal administrative services.
In the Mode of Service 60 Support Services field, select the mode of service for support services.
In the ADP Mode of Service field, enter the ADP Mode of Service.
In the Service Function - ADP field, select the ADP service function. The code for this selection populates the Service Function column in the ADP, or Short/Doyle electronic billing file. This field is the field from which the service code for the ADP Cost Report will be derived.
In the Service Function - DMH field, select the DMH service function. The code for this selection populates the Service Function column in the DMH Short/Doyle electronic billing file.
In the Units Of Time field, select the time unit. This selection populates the Units of Time column in the ADP or DMH Short/Doyle electronic billing, and CSI electronic submission files.
In the Service Function fields, select the code to populate the Service Function column of the CSI electronic submission file.
In the Service Function (CSI - Mode 5) field, select the service function for mode 5.
In the Service Function (CSI - Mode 10) field, select the service function for mode 10.
In the Service Function (CSI - Mode 15) field, select the service function for mode 15.
In the Service Type Code (270) field, select the service type from the drop-down list.
If a code is defined with a HIPAA Transaction Version of Version 5010 and it is used on a 4010 submission, an error will be shown on the error report.
In the ADP Cost Report - Program Code field, enter the appropriate program code. Used to identify the State Program Code associated with the deliverey of this service for ADP Cost Reporting.
It is important to note that when using this field service codes should be built specific to the ADP Program List. For example, if a particular type of service “Perinatal” falls under multiple ADP Programs (NNA, Drug Court, DMC, etc) this service will need to be built into myAvatar Cal-PM multiple times, once for each program. In doing this, to assure that users select the correct value when entering services, it is suggested that organizations leverage the service code filtering function applied via the Assign Services to Program section of the Program Maintenance form.

Time Frames

In the Worklist Frequency field, select how often the service will be included in inpatient or residential worklists. If Other is selected, in the Days of Inclusion field, enter the days in the format DD,DD where each day is a number from 1 to 31 or the letter “L” (last date of the month).
In the Days of Inclusion field, enter the number of days of inclusion.
In the Min Face to Face field, enter the minimum amount of face to face time for the service.
In the Max Face to Face field, enter the maximum amount of face to face time for the service.
In the Min Total field, enter the minimum total amount of time for the service.
In the Max Total field, enter the maximum total amount of time for the service.
In the Global Period field, enter the number of days a global period can exist for this service.
In the Can This Service be Rendered... field, select Yes to allow this service to be processed within the global period of other services.

Associations

In the Discipline(s) field, select the discipline(s) relating to this service.
In the Evidence-Based Practices / Service Strategies (CSI) field, select service strategies, to associate with the service code.
In the Service Requires A Medical Diagnosis field, select Yes to require that the service be rendered with an ICD-10 diagnosis code.
- If the service is not rendered with a medical diagnosis, service liability will be inhibited.
- Services are associated with a medical diagnosis in the Client Charge Input With Diagnosis Entry, and Spreadsheet Charge Input forms.
In the ARRA Measures fields, select which ARRA measures to include/exclude in an ARRA measures numerator or denominator.
In the Include Service in Exclusionary Value... field, select the ARRA measures for which this service provides an exclusionary value.
In the SNOMED Procedure field, enter the Hospital procedure SNOMED. This field appears when the IMO search is implemented. This is used for a procedure code SNOMED search for Meaningful Use CQM testing.
In the Is This Service An Intervention? field, select whether or not the service is an intervention. This is used by the CareRecordDataSetService data chunk Interventions to include the services.
In the Is This An Observation Code? field, select whether or not the code is used for observation.
In the Is This A Family Service? field select whether or not to designate this service in Progress Notes (Group and Individual) as a "billable" family service. This will notify the user if no group member has a "billable" family service code or if more than one client in the group has a "billable" family service code.
In the Secondary Activity field, select whether or not to designate this service as a secondary activity.
If Yes, enter the message to display in the user's To Do List in the Secondary Activity Message field.

National Drug code Information

In the National Drug Code field, enter the NDC number in the format: 01234-5678-90.
In the Drug Quantity field, enter the amount of the medication that is specific to this service code.
In the Unit or Basis of Measurement field, select the unity type by which to calculate the Drug Quantity amount.
When finished, click File Service Code.

Additional Sections

► SQL Tables

SYSTEM.batchload_tx_accepted
SYSTEM.billing_tx_master_table
SYSTEM.billing_tx_xref_table

► Registry Settings