DARTS Manual - Illinois Department of Human Services

Demographics

Self-Help Group Detail

If the answer to the Self-Help Group question is yes, specify how many times or:

RF - Refused

DK - Does Not Know

Specify if the client/patient had, in the past 30 days, interaction with family and/or friends that are supportive of his or her recovery:

Supportive Interaction

Y - Yes N - No

M

EDICAID

D

EMOGRAPHIC

S

CREEN

R - Refused D - Does Not Know

Completion of these fields is required if Medicaid is the payment source for the service. To avoid service rejections, ensure that the patient is Medicaid eligible on the dates of service prior to billing by:

 Checking the patient=s Medicaid card, or

 Calling 1-800-842-1461.

Attending Physician NPI

The ten-digit all numeric National Provider Identifier (NPI) of the Organization

=s Medical Director or physician authorized to oversee the patient‟s treatment episode and other medical procedures.

Third Party Liability (TPL) Information

If APPLICABLE, enter the following fields:

TPL Payer Name

The name of the paying organization from which the provider might expect some payment for treatment service (i.e., private insurance company, Medicare, Medicaid, etc.).

DASA HELP

– E-MAIL:

[email protected]

– FAX: 217.558.4656

| July 2013

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Demographics

TPL Code

The corresponding Healthcare and Family Services code for the insurance company name.

TPL Insured

=s Name

The name of the person on the policy.

TPL Insured

=s ID

The ID of the person on the policy (i.e., insurance company

=s ID, Medicaid ID, etc.).

D

EMOGRAPHIC

P

ROBLEM

A

REA

S

CREEN

Problem Area

The area that is the suspected or confirmed major reason that the client/patient requires Intervention or

Treatment services.

1 - Alcohol

2 - Drugs

3 - Alcohol and Drugs

4 - Co-Dependence

5 - None

6 - Alcohol/Drugs and Gambling

7 - Gambling

If the Problem Area is #5, indicating

Anone,@ the only allowable billing is for assessment. Also, when Anone@ is selected, the assessment date will default into the discharge date field. The primary, secondary, and tertiary fields of problem code, frequency, and administration routes will be automatically completed.

If the Problem Area is #6 - Alcohol/Drugs and Gambling, the problem code must be alcohol or drugs. One of the diagnosis codes must indicate an alcohol or drug-related problem and the gambling diagnostic code must be 312.31 or 312.30.

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SOFTWARE WEBSITE: HTTP://WWW.DHS.STATE.IL.US/PAGE.ASPX?ITEM=29747

Demographics

If the Problem Area is #7 - Gambling, the diagnosis code must be 312.31 or 312.30 and the primary, secondary, and tertiary fields of problem code, frequency and administration routes will be automatically completed.

Opioid Maintenance Therapy (OMT)

Identifies whether the use of Methadone or Buprenorphine is part of the patient

=s treatment at the provider‟s agency. If the patient is not an OMT patient at admission, but becomes one during the course of treatment, the provider should update this field. Enter

>Y= - Yes or >N= - No.

Primary Problem Code (NOMs)

This field provides additional information relative to the identified

AProblem Area@ field. For early intervention clients, this field identifies the area that precipitated the need for the early intervention service.

NOTE:

A01 - None@ may only be selected as the primary code if ANone@ is selected in the AProblem Area@ field.

01 - None

02 - Alcohol

03 - Cocaine/Crack

04 - Marijuana/Hashish - includes THC and any other Cannabis Sativa preparations

05 - Heroin

06 - Non-Prescription Methadone

07 - Other Opiates and Synthetics - includes codeine, hydrocodone, hydromorphone, meperidine, morphine, opium, oxycodone, pentazocine, propoxyphene, Tramadol and any other drug with morphine-like effects

08 - PCP - Phencyclidine

09 - Other Hallucinogens - Includes LSD, DMT, STP, Hallucingoens, Mescaline, Peyote, Psilocybin, etc.

10 - Methamphetamine

11 - Other Amphetamines - Includes Amphetamines, Phenmetrazine and other unspecified amines

12 - Other Stimulants - Includes Methylphenidate and any other stimulants

13 - Benzodiazepines - Includes Alprazolam, Chlordiazepoxide, Clonazepam, Clorazepate, Diazepam,

Flunitrazapam, Flurazepam, Halazepam, Lorazepam, Oxazepam, Prazepam, Temazepam,Triazolam

14 - Other Non-Benzodiazepan Tranquilizers - Includes Meprobamate, Tranquilizers, etc.

15 - Barbiturates - Includes Amobarbital, Pentobarbital, Phenobarbital, Secobarbital, etc.

16 - Other Non-Barbiturate Sedatives or Hypnotics - Includes Chloral Hydrate, Ethchlorvynol,

Glutethimide, Methaqualone, etc.

17 - Inhalants - Includes chloroform, ether, gasoline, glue, nitrous oxide, paint thinner, etc.

18 - Over-the-Counter - Includes aspirin, cough syrup, Diphenhydramine and other antihistamines, sleep aids and any other legally obtained non-prescription medication.

19 - Nicotine (Only available to use as a secondary or tertiary choice)

20 - Other - Includes Diphenylhydantoin/Phenytoin, GHB/GBL, Ketamine

21 - Gambling

22 - Ecstasy

23 - Rohypnol

24 - Steroids

25 - Ephedrine/Psuedoephedrine

Primary Frequency (NOMs)

1 - 0 within one month prior to admission

2 - 1

B3 times in the past month

3 - 1

B2 times in the past week

4 - 3

B6 times per week

5 - Daily

DASA HELP

– E-MAIL:

[email protected]

– FAX: 217.558.4656

| July 2013

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