Consultation/Secondary Provider: One-time
Purpose:
This is a consultation that is completed with the primary service provider and the child/family by another PIC provider. The consultations may be for different reasons, such as a closer look at the child’s functioning during a daily routine or activity.
Practice:
The consultant may be offering ideas about how to help facilitate success on a goal or outcome. This is a collaborative conversation and may or may not include an assessment tool beyond the provider’s and family’s observations and interview. The primary and the secondary will consult prior to visit so that the consulting provider knows what questions or concerns they are addressing. The primary service provider requests that a secondary provider attend the visit and may request that directly from a team member or in a team meeting.
Procedure:
- Signature forms: PWN, Consent to Evaluate, and optional ROI if consult results will need to be shared with outside agencies.
- Documentation: Consultation note in Raintree from the consulting provider about what occurred.
- Documentation from Primary service provider: Daily note that indicates FSC/service coordination with consulting provider and the outcome of the consultation-how the recommendation will be utilized.
- Billing for primary service provider: Family Service Coordination for the time spent in facilitating the interaction with the family.
- Billing for consulting provider (if appropriate): Billing codes used will be specific to your discipline, for example:
- OT/PT: Physical Performance test with report
- SLP: Speech/Language Evaluation
- SLP/OT for Feeding: Feeding Evaluation
- DS: Non Billable Evaluation
- SW: Social Work
Note: if a consultant conducts a second visit and is not added to the IFSP:
Therapy/FSC-- The typical practice is for a consulting provider to schedule a return visit to share evaluation results. Activities (such as therapy services or FSC) delivered by the consulting therapist during the visit should be indicated on the billing tab with times/units, however, the consulting therapist’s FSC activities are not billable since there is not a POC in place.
Evaluation--if evaluative activities take place during a second visit, the secondary provider activities are billable if evaluation occurs.
Consultation/Secondary Provider: On-going Services
Purpose:
When a provider, who is not the Primary Service Provider, is added to the IFSP with the permission of the family, to provide more support around a specific domain, such as motor development to the child, parent, and primary provider.
Practice:
After completing an evaluation, and/or interview and observation visit, the team subsequently recommends that the consultant provider be added to the IFSP for regular intervention/treatment due to child need for their intervention. They will support the development of the appropriate goals and then help facilitate success for goal or outcome. This all takes place within a collaborative conversation and may or may not include an assessment tool beyond the provider’s and family’s observations and interview. The primary and the secondary will consult prior to visit so that the consulting provider knows what questions or concerns they are addressing. The primary service provider requests that a secondary provider attend the visit and may request that directly from a team member or in a team meeting. The primary is responsible to adding the secondary to the appropriate goals on the IFSP.
Procedure:
- After the consult or evaluation, the primary service provider will add new service (if indicated) to the IFSP with appropriate start date and frequency for the quarter. Any new or revised goals need to be added to the IFSP/Plan of Care. All changes to IFSP services require a parent signature & initials, date and PWN.
- The consulting provider completes a Plan of Care and may use the following codes based on what occurs at the consultation visit
- OT/PT: Physical Performance test with report
- SLP: Speech/Language Evaluation
- SLP/OT for Feeding: Feeding Evaluation
- DS: Non Billable Evaluation
- SW: Social Work
- Documentation needed by the Primary Service Provider: Document the visit that occurs with the consulting provider in a Daily Note. This is evidence of collaborative teaming and is a FSC event.
- Documentation needed by the consultant/secondary: Prior to being added to the IFSP, document your consultation visit in a Consultation Note. After being added to the IFSP, complete Daily Notes. If there is a need to add objective findings, use a Consultation Note.
- Billing for Primary Service Provideres: Family Service Coordination if the consulting provider is also coaching you how to facilitate a specific position or activity, or you facilitated or supported the visit.
- Caseload: An opportunity to add the child to the secondary’s RT caseload, after signing off a Plan of Care note in child’s chart, please mark ‘Yes’ to the popup question ‘Do you want this child added to your caseload?’.
Noting and Billing In Raintree for Assessments that are completed by the Primary and Out of Normal Timeline Sequence
Purpose:
PSP therapists occasionally complete an assessment that is requested of them by the family, or they have recommended in the course of intervention/treatment. Documentation and billing will be completed by the primary and should note that this stands as a separate document from a daily note for that day. Another way a provider may think of this is that they have completed a consult to themselves.
Assessments are documented in a RainTree Consultation Note.
Complete the following tabs:
- Observation: enter a complete a description of the assessment activity completed, write-up of observations made during the assessment
- Summary of Findings: enter the interpretation and the recommendations
- Objective Findings: enter the test/assessment results
Billing Codes
OT, PT, SLP Therapists
Developmental Eval
Health and Beh Assessment
Developmental Therapists and Social Workers
Nonbill eval