BHRS Documentation
Manual for SMHS
Table of Contents
Introduction

BHRS Documentation Manualfor Specialty Mental Health Services
Introduction ............................................................................................................................ 4
Behavioral Health System of Care ............................................................................................................... 4
General Information About Compliance ..................................................................................................... 9
Fraud, Waste, and Abuse (FWA) ............................................................................................................... 10

Documentation Requirements

Alerts, Incident Reports, Breaches ............................................................................................................ 11

Access to SMHS and Medical
Necessity

Documentation Requirements .............................................................................................. 13

Screening Tools

Access to SMHS and Medical Necessity.................................................................................... 3

Overview ................................................................................................................................................... 13

Assessment

Overview ..................................................................................................................................................... 3

Additional Assessment Tools

Criteria to Access Specialty Mental Health Services (SMHS) ...................................................................... 4

Problem List
Care Planning
Coordination of Care

Screening Tools ..................................................................................................................... 10
CalAIM Adult and Youth Screening Tools for SMHS.................................................................................. 10

7/16/2024

ICC Eligibility Screening Tool ..................................................................................................................... 14

10/17/2024

Assessment ........................................................................................................................... 16

10/17/2024

Scope of Practice ....................................................................................................................................... 17

Coding Services

Assessment Domains ................................................................................................................................ 18

Progress Notes

Additional Assessment Components ........................................................................................................ 22

A – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

10/17/2024

Medical Necessity Criteria........................................................................................................................... 8

Discharges and Transfers

Appendices10/17/2024

Compliance ............................................................................................................................. 8

ComplianceDiagnosis

Date Updated

10/17/2024

Assessment Types ..................................................................................................................................... 16

10/17/2024

Assessment Timelines ............................................................................................................................... 19

10/17/2024

Multiple Teams or Providers for A Single Beneficiary............................................................................... 23

Additional Required Assessment Tools .................................................................................. 24
CANS and PSC-35 ....................................................................................................................................... 24

6/21/2024

BHRS SMHS Eligibility Tool ........................................................................................................................ 26

10/17/2024
Page 1 of 114

Diagnosis .............................................................................................................................. 29

BHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance

Date Updated

Diagnosis Scope of Practice....................................................................................................................... 30
Diagnosis and Billing.................................................................................................................................. 31
Other Diagnosis‐Related Issues ................................................................................................................. 32

Problem List .......................................................................................................................... 34
Care Plans ............................................................................................................................. 35
Pre-CalAIM Care Plans (Treatment Plans) ................................................................................................. 35
CalAIM Care Plans ..................................................................................................................................... 42

Documentation Requirements

Coordination of Care ............................................................................................................. 43

Access to SMHS and Medical
Necessity

Co-Occurring Substance Use Disorders..................................................................................................... 44

Screening Tools

Beneficiaries Shared Between BHRS and an MCP..................................................................................... 46

Discharges and Transfers ....................................................................................................... 48

Assessment

Transition of Care Tool .............................................................................................................................. 49

Additional Assessment Tools

Closing the Loop ........................................................................................................................................ 50

10/17/2024

Coding Services ..................................................................................................................... 53

Diagnosis
Problem List
Care Planning
Coordination of Care
Discharges and Transfers

Service Codes ............................................................................................................................................ 54

9/19/2024

Location Codes .......................................................................................................................................... 54

9/19/2024

Remote Services Location Codes .............................................................................................................. 55

9/19/2024

Blocked Billing Locations and Non-Reimbursable Services ....................................................................... 57

Progress Notes ...................................................................................................................... 73

Coding Services

General Information.................................................................................................................................. 73

Progress Notes

Progress Note Fields .................................................................................................................................. 75

AppendicesSame Day, Same Service Progress Notes .................................................................................................. 81

A – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

Individual Progress Notes.......................................................................................................................... 82

9/19/2024
9/19/2024

Group Progress Notes ............................................................................................................................... 83
Additional Requirement for Remote Service Notes .................................................................................. 85
Documenting Timely Access to Services ................................................................................................... 86
Tips for Writing Progress Notes ................................................................................................................ 87
Page 2 of 114

Sample Progress Notes.............................................................................................................................. 89

BHRS Documentation
Manual for SMHS

Date Updated

Appendix A ........................................................................................................................... 91
Service Code, Location Code, Time Field Matrix ....................................................................................... 91

Appendix B ........................................................................................................................... 93
Table of Contents
Introduction
Compliance

General Definitions of Services ................................................................................................................. 93

Appendix C ..........................................................................................................................102
Progress Note Templates ........................................................................................................................ 102

Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools
Diagnosis
Problem List
Care Planning
Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

Page 3 of 114

INTRODUCTIONBHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity

Behavioral Health System of Care
This manual provides the documentation standards and general descriptions of services provided by all BHRS mental healthprograms including BHRS contracted providers. This is a day‐to‐day resource for both clinical and administrative support staff.
This manual also provides basic information on services for individuals experiencing a co-occurring Substance Use Disorder(SUD), but is not meant to be a comprehensive overview of SUD services. A separate SUD Documentation Manual will be
provided in the future devoted to SUD services and programs.
Source material for this documentation manual includes, but is not limited to: Behavioral Health Information Notices published by the Department of Health Care Services (DHCS)

Screening Tools

 Medi-Cal billing manual published by the Department of Health Care Services (DHCS)

Assessment

 CalAIM Documentation Manuals published by the California Mental Health Services Authority (CalMHSA)

Additional Assessment Tools

 San Mateo County BHRS (SMC BHRS) internal policies and procedures

Diagnosis

 SMC BHRS Management Information System (MIS) Coding Manual

Problem List Other State and Federal regulatory documents

Care Planning Medi-Cal Manual For Intensive Care Coordination (ICC), Intensive Home Based Services (IHBS), and Therapeutic Foster
Care (TFC) Services for Medi-Cal Beneficiaries

Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

BHRS documentation standards were established to fulfill a core value of our system—the commitment to clinical and service
excellence. Furthermore, accurate and complete documentation protects us from risk in legal proceedings, helps us to comply
with regulatory requirements when we submit claims for services, and enables professionals to discharge their legal and ethicalduties. All of our services are documented using Medi‐Cal and Medicare documentation standards, regardless of funding
source. Services for beneficiaries with co‐occurring mental health and substance use disorders are documented using the rules
presented in this manual.

MENTAL HEALTH SERVICES
Services provided by Behavioral Health and Recovery Services (BHRS) are designed to improve behavioral health outcomes forbeneficiaries and families with substance use disorders, mental illness and/or co‐occurring disorders. These services are basedon the needs, strengths, and choices of beneficiaries and their families, who are involved in planning and implementing
treatment. Services are based on the beneficiary’s/family’s recovery goals concerning their own life, functional impairment(s),symptoms, disabilities, strengths, life conditions, cultural background, spirituality and rehabilitation readiness. Services are
Page 4 of 114

BHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools
Diagnosis
Problem List
Care Planning
Coordination of Carefocused on achieving specific objectives to support the beneficiary in accomplishing their desired goals. The unique values andstrengths of both Mental Health and Substance Use providers are honored while we work together to create maximum
opportunities to combine best practices in prevention, assessment, and treatment within our integrated system.
Mental Health Services are individual, group, or family therapies and interventions that are designed to reduce mental disability
and/or facilitate improvement or maintenance of functioning consistent with the goals of learning, development, independent
living and enhanced self‐sufficiency.

CalAIM
Established in 2021 by AB 133, the California Advancing and Innovating Medi-Cal (CalAIM) Initiative is an innovative, multi-year
program designed to improve the state’s Medi-Cal health insurance system.
California's Medi-Cal program is the largest Medicaid program in the country and is charged with providing care forapproximately 15 million enrollees, or one third of California’s population.
To ensure affordability while maintaining quality and improving health care outcomes, CalAIM was created as California’s
newest approach to reform Medi-Cal, including changes to managed care plans and reimbursement of behavioral health plans.

CALAIM’S GOALS ARE:
Identify and manage
member risk and needthrough whole personcare approaches andaddressing social
determinants of healthMove Medi-Cal to a moreconsistent and seamlesssystem by reducing
complexity and increasing
flexibility

Improve quality outcomes
and drive delivery systemtransformation throughvalue-based initiatives,modernization of systems
and payment reform

Discharges and Transfers
Coding Services
Progress Notes
Appendices

We have updated this documentation manual to include the CalAIM updates mandated by DHCS to help you learn how toincorporate them into your practice. It may feel like a lot when starting these new changes, but gradually it will become as
seamless as your practice today.

A – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

Page 5 of 114

Guide to Reading this Manual
MENU BARBHRS Documentation
Manual for SMHS

This menu bar has been added to the left of each page. The current section you are in will behighlighted in orange in the menu. Each item is also linked to the appropriate section in the
manual. This means that if you access the manual on a computer, you can click on the section
title to navigate to the first page of that section.

Table of Contents
Introduction
Compliance
Documentation Requirements

Compliance Alerts
Information here.

Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools

Documentation
Tips will be listed here

COMPLIANCE ALERTS
This manual is comprised mostly of documentation requirements that are necessary forcompliance to state and federal regulations. Red boxes call out specific elements of theprocess that many staff forget, or might not be aware of.

DOCUMENTATION REMINDERS/TIPSThis manual contains a large amount of information regarding documentation requirements!
Green boxes are used to provide tips to staff about documentation, such as documentation
reminders and helpful tips on how to document certain services.

Diagnosis
Problem List
Care PlanningOTHER
USEFUL INFO

Coordination of Care

Information here.

OTHER USEFUL INFORMATION
Sometimes staff have questions about terminology or other information that is general tobehavioral health or how the system functions. This box provide this type of information tostaff.

Discharges and Transfers

POLICIES TO REVIEW

Coding Services
Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

RELATED POLICIES TO
REVIEW
The following are the main
policies related to Topic.
Policy XX-XX: Name of Policy

Policies related to the topic are noted in a yellow box. The policies that are listed are
the main policies associated with the topic, but does not necessarily include ALL
policies related to the topic.
Please contact your program supervisor directly or contact the BHRS QM Ask inbox at
HS_BHRS_ASK_QM@smcgov.org if you have questions about what additional policies
might be applicable to your program.

BHRS is currently in the process of updating several policies to reflect up-to-date information. If “Update in Progress” is written inthis yellow box, it means that staff should follow the instructions in this manual until the policy updates are finalized.
Page 6 of 114

Terminology for Persons Receiving Services
BHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance

As the State and the Behavioral Health system as a whole continues to refine and adapt language used to describe individuals
who are eligible for, have received, or are receiving behavioral health services, staff will find that various documents, trainings,
policies, etc. use different terms when referencing this population. Sometimes the differences are due to certain documents not
yet being updated, other times it is because there is a specific reason for a particular term being used based on the use of theterm. At times, it may be due to character limitations in the EHR, and so on and so forth.
Staff are not required to use a particular term over another, but should be sure to follow HIPAA guidelines and use appropriate
terminology when determining what terms to use. Below are three of the main terms staff might see across different sources
when referring to individuals who are eligible for and /or receive behavioral health services. All are acceptable for staff to use
when referencing individuals who are seeking or receiving behavioral health services.

Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools

ClientConsumer

BeneficiaryMemberAssessment
Additional Assessment Tools
Diagnosis
Problem List

Typically used to refer toindividuals who are receiving
services from BHRS.

Typically used to refer to individuals who
are Medi-Cal eligible but might or might
not be receiving services from BHRS.

Care Planning
Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes

How to Get Help
This manual is BHRS policy and is the resource for all documentation issues. The Quality Management website provides links toother resources as well as trainings, guides and other helpful documents.

 Got a question? Send QM an email at HS_BHRS_ASK_QM@smcgov.org

AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

 Visit us on the web at www.smchealth.org/bhrs/qm
 Access our recorded webinars via the LMS. For instructions on how to access the LMS (for BHRS Staff and Contracted
Agencies) please visit the BHRS QM website at www.smchealth.org/bhrs/qm

 View our Compliance Program http://www.smchealth.org/bhrscompliance‐program
Page 7 of 114

COMPLIANCE
BHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity

BHRS has adopted a Compliance Plan to express our commitment to providing high‐quality health care services in accordancewith all applicable federal, state and local rules and regulations. A key component of the Compliance Plan is the assurance thatall services submitted for reimbursement are based on accurate, complete and timely documentation. Read more about the
BHRS Compliance Program here: https://www.smchealth.org/bhrs-compliance-program.
It is the personal responsibility of all providers to submit a complete and accurate record of the services they provide, and to
document in compliance with applicable laws and regulations. The QM program strives to support the provider network in theprovision of quality care, and to maintain programmatic, clinical, and fiscal integrity.
All services shall be documented as described in this Documentation Manual, and in accordance with any amending orprocedural bulletins, memos, alerts or policies issued prior to or following its adoption.
RELATED POLICIES TO REVIEW

Screening Tools
Assessment

The following are the main policies related to Compliance.

Additional Assessment Tools
Diagnosis
Problem List
Care Planning
Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes
Appendices

Please note that there are additional policies not listed below that may be related to a particular population, program, or
situation.
Policy 16-03: San Mateo County BHRS Compliance Plan
Policy 04-05: Compliance Improvement Hotline
Policy 03-15: Compliance Officer – Duties
Policy 03-16: Compliance Committee
Policy 16-05: Non-Retaliation and Non-Intimidation for Reporting Compliance Concerns
Policy 22-04: Documentation Requirements or all SMHS, DMC, and DMC-ODS Services
Policy 19-08: Credentialing and Re- Credentialing Providers

A – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

Page 8 of 114

General Information About Compliance
BHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements

Notes Must Be Accurate and Factual
It is critically important for staff to be aware of their essential role in ensuring thecompliance of our services with all pertinent laws. The progress note is used to record
services that produce claims.
Errors in documentation (e.g., using incorrect locations or service charge codes)
directly affect our ability to submit true and accurate claims. For this reason,compliance is the personal responsibility of all clinical and administrative staff at BHRS.

Fraud, Waste, Abuse Alert
Please keep in mind that when
you write a billable progressnote, you are submitting a billto the State.

Access to SMHS and Medical
Necessity

General Rules for Compliant Documentation

Screening Tools

To ensure compliance, documentation for all services provided must observe the following overarching rules:

Assessment•

Accurately reflect the activity, location, and duration of each service.

Additional Assessment Tools•

Notes should be written within 3 business days of the date of the service, with the exception of crisis services, whichshould be documented within 24 hours of the service.

•

The date of a late entry must be clearly identified in the documentation.

•

Notes must be signed legibly, including your discipline, or electronically signed in the electronic medical record.

•

All services will be based on a current assessment, problem list, and, when applicable, current treatment plan.

Discharges and Transfers•

Services must be provided within the staff person’s scope of practice, as indicated in this manual.

Coding Services•

Use Service Code 55 or 550 for services that are not claimable (see “Non‐Reimbursable Activities” for more information
about non-claimable services)•

Contractors that submit billing or invoices are required to attest that all billing is correct. Contractors that submit bills forservices that were not provided are subject to fines and/or loss of their contract with San Mateo County.

Diagnosis
Problem List
Care Planning
Coordination of Care

Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

Page 9 of 114

Fraud, Waste, and Abuse (FWA)
BHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools

DHCS monitors Medi-Cal behavioral health delivery
systems for compliance with their documentation
requirements, and deviations from therequirements may require corrective action plans.
DHCS’ oversight will include verifying that services
provided to Medi-Cal members are medicallynecessary, and that documentation complies withthe applicable state and federal laws, regulations,and the MHP Contract. Recoupment shall befocused on identified overpayments and fraud,
waste, and abuse.

WHAT IS A MENTAL HEALTH PLAN (MHP)?
Specialty Mental Health Services (SMHS) are managed locally bycounty MHPs under an MHP Contract with the CA Department of
Health Care Services. San Mateo County BHRS is an MHP.
In addition to managing the benefit, MHPs directly deliver and/or
contract with Community-Based Organizations (CBOs) orgroup/individual providers to deliver services to individuals with MediCal who have significant and/or complex care needs.

Understanding FWA
All staff are required to complete FWA training at onboarding and annually, which includes reviewing BHRS’ Compliance Plan
and associated policies. The definitions below are provided to remind staff of what actions constitute Fraud, Waste, and Abuse;
however, staff should refer back to the Compliance Bundle trainings and Compliance Plan and policies to learn more about FWA.

Diagnosis

FRAUD

Problem List

Coordination of Care

Fraud means an intentional deception or misrepresentation made by a personwith the knowledge that the deception could result in some unauthorized benefit
to himself or some other person. It includes any act that constitutes fraud underapplicable Federal or State law. (42 C.F.R. § 433.304, 455.2)

Discharges and Transfers

WASTE

Coding Services
Progress Notes

Waste includes inappropriate utilization of services and misuse of resources.
(Medicaid and CHIP Payment and Access Commission)

Appendices

ABUSE

Care Planning

A – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

Abuse means provider practices that are inconsistent with sound fiscal, business,or medical practices, and result in an unnecessary cost to the Medicaid program
or in reimbursement for services that are not medically necessary or that fail tomeet professionally recognized standards for health care. It also includes
member practices that result in unnecessary costs to the Medicaid program. (42
C.F.R. § 455.2)

Fraud

Waste

Abuse

Page 10 of 114

Alerts, Incident Reports, Breaches
BHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools
Diagnosis
Problem List

Critical Incident Reports
The Critical Incident Report is a CONFIDENTIAL reporting tool todocument occurrences inconsistent with usual administrative or
medical practices.
A Critical Incident is an event or situation that creates a significant
risk of substantial or serious harm to the physical or mental health,safety or well‐being of a beneficiary/beneficiary’s family member,volunteer, visitor or staff.
Reporting and analyzing Critical Incidents is a recognized Quality
Improvement (QI) mandate and process. The Critical Incident
reporting system also provides a mechanism to organize
information concerning potential breaches of beneficiary privacy,
and to document mitigation efforts once a breach is recognized.

RELATED POLICIES TO REVIEWThe following are the main policies related toCritical Incident Reports.
Please note that there are additional policies not listed
below that may be related to a particular population,
program, or situation.
Policy 93-11: Critical Incident Reporting

Critical Incidents must be reported in writing and sent to BHRS Quality Management within 24 hours. BHRS Quality
Management must report any required breaches to the DHCS Privacy Office (within 24 hours for federal breaches, within 72
hours for all others).

Care Planning

Critical Incident reports must NOT be scanned or otherwise included into the beneficiary’s chart and should NOT bereferenced in a progress note.

Coordination of Care

WHEN TO REPORT AN INCIDENT

Discharges and Transfers

Below are examples of when to complete an incident report.

Coding Services•

Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

An email sent to the incorrect email address with the beneficiary’s
Protected Health Information (PHI), including name, date of birth,and Social Security Number.

•

Beneficiary slipped in the lobby of clinic.

•

Facility elevator stopped functioning and staff were trapped inside.

Compliance Tip
When in doubt, send it out!
If you’re not sure if an incident report
should be submitted, you should go ahead
and submit one!

Remember, if you are unsure if incident requires the submission of an incident report, go ahead and send it – there is a greaterrisk if you do NOT send an incident report when it was required than sending one when you did not need to.
Page 11 of 114

Client Alerts & Urgent Care PlanBHRS Documentation
Manual for SMHS
Table of Contents
Introduction
ComplianceThis section is applicable for programs that use BHRS Avatar.
Urgent care messages are used to notify staff about special
circumstances which apply to individual mental health clients. For
example, urgent care messages may provide information about violent
behavior, use of weapons, substance abuse, drug seeking behaviors, coinsurance, hospitalization issues, and other factors which might impact
clinical decisions, particularly those by an officer of the day, emergency,
or crisis staff who have limited knowledge about the client.

Documentation Requirements

To set an Urgent Care Plan, complete both a Client Alert and an Urgent
Care Plan. In Avatar, use the “Urgent Care Plan Bundle.”

Access to SMHS and Medical
Necessity

CLIENT ALERTS

Screening Tools

RELATED POLICIES TO REVIEWThe following are the main policies related toUrgent Care Messages.
Please note that there are additional policies notlisted below that may be related to a particular
population, program, or situation.
Policy 97-09: Urgent Care Messages

The Client Alert is a pop‐up window that alerts any user in Avatar that an Urgent Care Plan is posted for the beneficiary.

Assessment

URGENT CARE PLAN

Additional Assessment Tools

The Urgent Care Plan contains detailed documentation regarding the alert. It is a notification placed in the Avatar System thatwill be seen by any user opening the beneficiary’s Avatar chart, including PES and 3AB. It is a statement of special problems,
concerns and instructions about a beneficiary.

Diagnosis
Problem List
Care Planning
Coordination of Care

TYPES OF CLIENT ALERTS
There are four types of clinical alerts. Choose the appropriate alert.
Discharges and Transfers

Used to alert BHRS of medication issues. Onscreen Message says “PES ‐ Long Term Injectable Medication Alert‐
See Urgent Care Plan.”

Coding Services
Progress Notes

Injection

Medication
Used to alert BHRS of medication issues. Onscreen Message says “Medication Urgent Care Plan on File.”

AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

Care Message
Used for routine alerts. Onscreen Message states: “Please review the Urgent Care Plan for information.”

Care Alert
Used for urgent messages and safety notices. This should be viewed as soon as possible, without the beneficiary viewing.
Onscreen Message states: “HIGH PRIORITY ‐ Please review the Urgent Care Plan in Chart Review.”
Page 12 of 114

DOCUMENTATION REQUIREMENTS
BHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment

Overview
General Principles of Documentation
 Services must be clinically appropriate based on the clinical

RELATED POLICIES TO REVIEW

documentation that exists in the medical record (e.g., Assessment,
Problem List, and, when applicable, the Care Plan).

The following are the main policies
related to Documentation
Requirements.

 Clinical documentation should follow all relevant requirements(including, but not limited to: federal, state, county, and funding
requirements) as well as best practice to ensure that a beneficiary’s
medical record is up-to-date and accurate.

 Services must be provided within the staff person’s scope of practice, as

Additional Assessment Tools

indicated in this manual.

 Contractors that submit billing or invoices are required to attest

Diagnosis
Problem List
Care Planning
Coordination of Care
Discharges and Transfersthat all billing is correct. Contractors that submit bills for services that w
ere not provided are subject to fines and/or loss of their contract with S
an Mateo County.

Please note that there are additional
policies not listed below that may be related
to a particular population, program, or
situation.
Policy 22-04: Documentation Requirements
for all SMHS, DMC, and DMC-ODS

Required Clinical Documentation

Coding Services

In order to comply with all state and federal documentation requirements, a chart must have all of the following items
completed according to time frames established by BHRS policies and State and Federal regulations:

Progress Notes

 Adult or Youth Screening Tools (if applicable)

 Trauma Screening Tool (To Be Determined…)

Appendices Assessments (including Diagnosis and Mental Status

 Problem List

Exam)

A – Service Code, Location
Code, Time Field Matrix

 CANS (beneficiaries ages 6 through 20 years old)B – Service Definitions

 PSC-35 (beneficiaries ages 3 through 18 years old) Transition of Care Tool (if applicable)

C – Progress Note Templates

 ICC Eligibility Screening (beneficiaries under 21 years of Progress Notes

Last Updated: 10/17/2024

age) Care Planning Requirements (for select services andprograms)

Page 13 of 114

Scope of Practice
BHRS Documentation
Manual for SMHS
Table of Contents
Introduction

BHRS has provided a Scope of Practice Matrix to support staff in understanding what clinical documentation falls under theirscope of practice. This includes, but is not limited to, information regarding: What can be practiced under the scope of practice of a Clinical Trainee Who requires supervision by an Licensed Practitioner of the Healing Arts (LPHA) to provide services and complete clinicaldocumentation with the co-signature of the LPHA.

Compliance

Guidelines for Co-Signatures on Clinical Documentation

Documentation Requirements

Co-signature is not meant to enable someone to provide services beyond his/her scope of practice. For some categories of staff,
such as clinical trainees, the co-signer must be an LPHA. For some other categories of staff, such as Peer Support Workers,
unlicensed staff may co-sign notes for services that fall within their scope of practice only—e.g., rehabilitation or casemanagement services. If you are unsure if a licensed or unlicensed staff must co-sign your notes, please ontact QM.

Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools

Examples where co-signatures are allowed and who can co-sign: Licensed clinical supervisor co-signing trainee’s notes.
 MD co-signing prescriptions for a resident before the resident is licensed.

Diagnosis
Problem List
Care Planning
Coordination of Care
Discharges and Transfers
Coding Services

 Co-signing the work of unlicensed staff before the required education or experience for independent recording ofservices has been acquired.
An example of where a co-signature is not permitted:
 Co-signing a diagnosis, mental status exam, or a clinical formulation without the co-signer knowing or seeing the client is
not permitted. The only exception to this would be a clinical supervisor co-signing the diagnosis, MSE or clinicalformulation, completed by a trainee, after close supervision.

Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

Page 14 of 114

Documentation Timelines (General List)
BHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools
Diagnosis
Problem List
Care Planning
Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

The following are a mix of required and suggested timeframes. Most items should also be updated whenever there is asignificant clinical change. For more specific guidance on completion of each item below, please see the appropriate section inthis manual as well as any associated BHRS policies related to that section.

Pre-Admission

Only Administered by Some Programs• CalAIM Screening Tool

Admission

Complete within approximately 60 Days of Admission• Initial Assessment• Problem List
• CANS and PSC-35 (if applicable)• ICC Eligibility Screening Tool (if applicable)• Care Plan (if applicable)

Every 6 Months• CANS and PSC-35 (if applicable)• Review Problem List (Update as needed)

Check with Your Supervisor
The list to the left comprises only
the main documentation
requirements for a majority of
BHRS clients. However, it is not an
exhaustive list of ALL forms thatneed to be completed.
Some programs and somecategories of clients require
additional forms to be completed
at various points in treatment. Staff
should check with their supervisor
to ensure that all documentation
required for the program and/or
client are completed.

Every 1 Year
• Care Plan (if applicable)• Review of Assessment (Update as needed)• And all the applicable items in the "Every 6 months" category above.

Every 3 Years• Reassessment Form

Discharge

Prior to Closing Episode• Reassessment Form (to document reason for discharge or transfer)• Problem List (to update to reflect discharge diagnosis)• Transition of Care Tool (if applicable)• CANS and PSC-35 (if applicable)

Page 15 of 114

ACCESS TO SMHS AND MEDICAL NECESSITYBHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance

Overview
CalAIM has introduced a more nuanced manner of determining whether or not a beneficiary is eligible to receive Specialty
Mental Health Services. This was done by breaking the concept of “Medical Necessity” into two types of criteria for receiving
SMHS. The first type is criteria for “Access to SMHS” while the second type is called “Medical Necessity.” The next sections
describe each set of criteria.

Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools

Access to SMHS

Medical Necessity• Answers the question: Is theindividual eligible to receive
SMHS?

• Answers the question: Is theservice provided clinicallyappropriate?

Diagnosis
Problem List
Care Planning
Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes

RELATED POLICIES TO REVIEWThe four policies listed below are the main policies regarding access and medical necessity.
Please note that there are additional policies not listed below that may be related to a particular population,
program, or situation.
Policy 22-01: Criteria for Beneficiary Access to SMHS, Medical Necessity and Other Coverage Requirements

AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions

Policy 22-03: No Wrong Door for Mental Health Services
Policy 22-04: Documentation Requirements for all SMHS, ODS and DMC-ODS
Policy 23-01: Adult and Youth Screening and Transition of Care Tools

C – Progress Note Templates
Last Updated: 10/17/2024

Page 16 of 114

Criteria to Access Specialty Mental Health Services (SMHS)BHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools
Diagnosis

Criteria to Access SMHS is used to determine if a beneficiary is eligible to access
SMHS. There are different Access Criteria for Adults and Youth which will be outlinedin the next few pages, but a feature shared across both age groups is that abeneficiary is no longer required to have an identified mental health diagnosis toreceive services. This opens up the ability for health plans to provide clinicallyappropriate mental health services prior to the determination of a diagnosis.
Therefore, Specialty Mental Health Services provided during the assessment process
are no longer limited to assessment activities. This is related to the “No Wrong
Door” policy that aims to ensure that beneficiaries are not delayed in receiving
medically necessary services.

A Note About
Mental Health Diagnosis
Except for psychiatric inpatient
hospital and psychiatric healthfacility services, a mental healthdiagnosis is not a prerequisite foraccess to covered SMHS.

Also related to Criteria to Access to SMHS is the CalAIM Adult and Youth Screening Tool. The CalAIM Screening Tool determines
under which system the beneficiary should access assessment services, however it does not determine level of care for ongoingtreatment or which services are medically necessary. These determinations are made during clinical assessment. Therefore, theScreening Tool must only be used when determining if a client should receive their clinical assessment through BHRS or an
MCP.

SMHS Access Criteria for Adults

Problem List

SMHS Access Criteria for ADULTS

Care Planning

For beneficiaries 21 years of age or older, a county MHP shall provide covered SMHS for beneficiaries who meet both of thefollowing Criteria, (1) AND (2) below:

Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix

Criteria (1)The beneficiary has one or both of the following:a. Significant impairment, where impairment is defined
as distress, disability, or dysfunction in social,occupational, or other important activities, AND/OR
b. A reasonable probability of significant deteriorationin an important area of life functioning.

Criteria (2)The beneficiary’s condition as described in paragraph (1) is due toeither of the following:a. A diagnosed mental health disorder*, OR
b. A suspected mental disorder that has not yet been
diagnosed.

B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

Page 17 of 114

SMSH Access Criteria for YouthBHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools

SMHS Access Criteria for YOUTH
For enrolled beneficiaries under 21 years of age, a county MHP shall provide all medically necessary SMHS required pursuant
to Section 1396d(r) of Title 42 of the United States Code. Covered SMHS shall be provided to enrolled beneficiaries who meeteither Criteria (1) OR (2) below:
Criteria (1)The beneficiary has a condition placing
them at high risk for a mental healthdisorder due to experience of trauma
evidenced by ANY of the following:

The beneficiary meets both of the following requirements in a) AND b), below:

a. Scoring in the high-risk range undera trauma screening tool approvedby the department,* OR

a. The beneficiary has at least one of thefollowing:

Assessmentb. Involvement in the child welfare
system, OR

Additional Assessment Tools

c. Juvenile justice involvement, OR

Diagnosis

d. Experiencing homelessness

Problem List
Care Planning
Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions

Criteria (2)* MHPs are not required to implementa trauma screening tool until DHCS
issues additional guidance regarding
approved tool(s) for the purposes of
SMHS access criteria. As of the
publication of this manual. DHCS has not
yet provided this guidance.

i.

A significant impairmentii.

A reasonable probability ofsignificant deterioration in an
important area of life
functioningiii.

A reasonable probability of
not progressing
developmentally as
appropriate.

iv.

A need for SMHS, regardlessof presence of impairment,that are not included within
the mental health benefits
that a Medi-Cal managed careplan is required to provide.

b. The beneficiary’s condition as
described above (Criteria 2a) isdue to one of the following:i.

A diagnosed mental
health disorder,
according to the criteriaof the current editions of
the DSM-5 and the ICD10.

ii.

A suspected mental
health disorder that has
not yet been diagnosed.

iii.

Significant trauma
placing the beneficiary at
risk of a future mental
health condition, basedon the assessment of alicensed mental healthprofessional.

If a beneficiary under age 21 meets the criteria as described in Criteria (1) above, the beneficiary meets criteria to access
SMHS; it is not necessary to establish that the beneficiary also meets Criteria (2) above.

C – Progress Note Templates
Last Updated: 10/17/2024

Page 18 of 114

Population Categories
BHRS Documentation
Manual for SMHS

The tables on the next two pages are provided to support staff’s understanding of what it means to be involved in the Child
Welfare or the Juvenile Justice systems, and what qualifies as “experiencing homelessness.”

Population Categories
Table of Contents

For use with Criteria (1) for beneficiaries under 21 years of age.

Introduction

Child Welfare Involvement

Compliance

A child can have involvement in child welfare whether thechild remains in the home or is placed out of the home. A
child who meets ANY of the criteria below falls into thiscategory:

The beneficiary is considered to fall under this category if thebeneficiary:

1) Has an open child welfare services case, meaning:

1) Has ever been detained or committed to a juvenile justicefacility, OR

Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools
Diagnosis
Problem List
Care Planning
Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes
Appendicesa) The child is in foster care or in out of home care,including both court-ordered and by voluntaryagreement, orb) The child has a family maintenance case (preplacement or post-reunification), including bothcourt ordered and by voluntary agreement
2) Is determined by a child welfare services agency to beat imminent risk of entering foster care but able tosafely remain in their home or kinship placement withthe provision of services under a prevention plan
3) Is a child whose adoption or guardianship occurred
through the child welfare system

Juvenile Justice Involvement

2) Is currently under supervision by the juvenile delinquency
court and/or a juvenile probation agency, OR
3) Has ever been in custody and held involuntarily throughoperation of law enforcement authorities in a juvenile
justice facility, including youth correctional institutions,juvenile detention facilities, juvenile justice centers, andother settings such as boot camps, ranches, andforestry/conservation camps, OR
4) Is on probation, or has been released home ordetained/placed in foster care pending or post-adjudication,
under probation or court supervision, participating injuvenile drug court or other diversion programs, and who isotherwise under supervision by the juvenile delinquency
court and/or a juvenile probation agency.

A – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

Page 19 of 114

Population Categories

BHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools
Diagnosis
Problem List
Care Planning
Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes

For use with Criteria (1) for beneficiaries under 21 years of age.
Experiencing Homelessness
The beneficiary meets the definition established in section 11434a of the federal McKinney-Vento Homeless Assistance Act.13
Specifically, this includes beneficiaries who fall under either criteria A OR B below:A) Beneficiaries who lack a fixed, regular, and adequatenighttime residence (within the meaning of section
103(a)(1) of the Act);

B. Children/Youth who meet ANY of the following criteria:i. Are sharing the housing of other persons due to lossof housing, economic hardship, or a similar reason;
are living in motels, hotels, trailer parks, or camping
grounds due to the lack of alternative adequate
accommodations; are living in emergency ortransitional shelters; or are abandoned in hospitals;ii. Have a primary nighttime residence that is a public or
private place not designed for or ordinarily used as aregular sleeping accommodation for human beings(within the meaning of section 103(a)(2)(C));
iii. Are living in cars, parks, public spaces, abandonedbuildings, substandard housing, bus or train stations,or similar settings;
iv. Migratory children (as such term is defined in section
1309 of the Elementary and Secondary Education Act
of 1965) who qualify as homeless for the purposes ofthis subtitle because the children are living incircumstances described in clauses (i) through (iii).

AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

Page 20 of 114

Medical Necessity Criteria
BHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools

All Medi-Cal services provided to persons in care need to meet the standard of being “medically necessary”. The definitions of
medical necessity are somewhat different, based upon the age of the person in care.
Pursuant to Welfare and Institutions Code section 14184.402(a), for beneficiaries aged 21 and older, a mental health service isconsidered “medically necessary” when it is “reasonable and necessary to protect life, to prevent significant illness or significant
disability, or to alleviate severe pain” as set forth in Welfare and Institutions Code section 14059.5.
For individuals under 21 years of age, a service is “medically necessary” or a “medical necessity” if the service meets thestandards set forth in Section 1396d(r)(5) of Title 42 of the United States Code. This section requires provision of all Medicaidcoverable services necessary to correct or ameliorate a mental illness or condition discovered by a screening service, whether or
not such services are covered under the State Plan. Furthermore, federal guidance from the Centers for Medicare & Medicaid
Services (CMS) makes it clear that mental health services need not be curative or restorative to ameliorate a mental healthcondition. Services that sustain, support, improve, or make more tolerable a mental health condition are considered toameliorate the mental health condition, and are thus medically necessary and covered as EPSDT services.
Pre-CalAIM, medical necessity required a mental health diagnosis that was included in a list of select diagnoses published by the
Department of Health Care Services (DHCS). With the implementation of CalAIM, this “included diagnosis” list is no longer
published and an “included diagnosis” is no longer required to establish medical necessity.

Diagnosis
Problem List
Care Planning
Coordination of Care

Medical Necessity Criteria for SMHS
Beneficiaries
under 21 years ofage

Discharges and Transfers
Coding Services

A – Service Code, Location
Code, Time Field Matrix
B – Service Definitions…the service is necessary to correct or ameliorate a mental illness or condition
discovered by a screening service, whether or not such services are covered under theState Plan.
Services that sustain, support, improve, or make more tolerable a mental healthcondition are considered to ameliorate the mental health condition, and are thus
medically necessary and covered as EPSDT services.

Progress Notes
Appendices

For beneficiaries under 21 years of age, a service is “medically necessary” or a “medical
necessity” if…

Beneficiaries
21 years of age
and older

For beneficiaries 21 years of age or older, a service is “medically necessary” or a“medical necessity” when it is…
…reasonable and necessary to protect life, to prevent significant illness or significant
disability, or to alleviate severe pain…

C – Progress Note Templates
Last Updated: 10/17/2024

Page 21 of 114

Documenting Access Criteria and/or Medical Necessity Criteria
BHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance

The beneficiary’s medical record should demonstrate that theservices provided, even during this assessment period, were clinicallyappropriate. Clinical Documentation should support the ultimate
determination of whether or not criteria to access SMHS was met
and whether or not the services provided were medically necessary.
Remember, under CalAIM, services rendered during the assessment
period remain reimbursable even if the assessment ultimately
indicates the beneficiary does not meet criteria for SMHS.

THE ASSESSMENT – The completion of an Assessment establishes

Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools
Diagnosis
Problem List
Care Planning
Coordination of Carethe foundation of the seven domains that develops a clinicalunderstanding of the beneficiary's care needs, determines anaccurate diagnosis, confirms the appropriate treating system, andwhat services are medically necessary to support the Beneficiary intheir goals so they can thrive in their community.

Problem List
/Diagnosis

Assessment

THE PROBLEM LIST /DIAGNOSIS – The problem list is a list of symptoms, conditions, diagnoses, and/or risk factors identified
through assessment, psychiatric diagnostic evaluation, crisis encounters, or other types of service encounters.
THE PROGRESS NOTE – Progress Notes document delivered services that are clinically appropriate for the problems/diagnoses
identified on the problem list and the goals of the mental treatment plan. Each progress note shall provide sufficient detail tosupport the service code selected for the service type as indicated by the service code description.
The connection between the above components should be reviewed and updated on a regular basis to ensure that interventions
are consistent with current symptoms/impairments and behaviors documented in the Clinical Record.

Discharges and Transfers

DIAGNOSTIC CRITERIA

Coding Services

While clinically appropriate services are covered and reimbursable prior to diagnostic criteria being met, and a person may
access necessary services prior to determining a diagnosis, an ICD-10 code must be assigned to submit a service claim forreimbursement. See Diagnosis section for more information on this requirement.

Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

Page 22 of 114

SCREENING TOOLSBHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools
Diagnosis
Problem List
Care Planning
Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

CalAIM Adult and Youth Screening Tools for SMHS
Important Information about
Emergency /Urgent Requests
The Adult and Youth Screening Tools shallnot replace protocols for emergencies orurgent and emergent crisis referrals. For
instance, if a beneficiary is in crisis orexperiencing a psychiatric emergency,
emergency and crisis protocols shall befollowed.

Persons seeking care may access treatment in several different ways including
self-referral, referral from another behavioral health practitioner, or a primary
health care provider, etc. Persons seeking care, and sometimes even thereferring provider (if the provider did not do a screening or assessment) may
not always know which system (BHRS or MCP) is the appropriate system forthe individual’s current needs. To ensure that beneficiaries receive timely carefrom whichever delivery system they initially seek care, DHCS has createdstandardized screening tools – one for adults aged 21 and over, and one foryouth under age 21 – to facilitate and standardize this process. The goal is toensure that beneficiaries seeking care have access to the right care in the rightplace at the right time, regardless of what door they initially enter through.

Standardized Screening Tools
PURPOSE OF THE SCREENING TOOL
The Adult and Youth Screening Tools are designed to capture informationnecessary to determine where a beneficiary should be referred for anassessment. A beneficiary who scores within a specific range on thescreening tool will either be referred to an MCP or one of BHRS’ countyoperated or contracted programs to receive a clinical assessment.
Completion of the Screening Tool is not considered an assessment and do
not replace assessments. Once the screening tool has been administered,
the beneficiary will be referred to the appropriate Medi-Cal mental healthdelivery system for a clinical assessment that will determine the level ofcare and medically necessary services.
A second screening should not be administered upon referral to thedelivery system if the referral originated as a result of the use of the
Screening Tool. For example, if a beneficiary is referred to BHRS based ona score generated by Kaiser (Medi-Cal), BHRS must offer and provide atimely assessment without requiring an additional screening.

WHAT IS A MANAGED CARE
PLAN (MCP)?
MCPs are responsible for the majority of
medical (physical health care) benefits. They
also provide mental health services to thosewith less significant /complex care needs.
These services (also called “mild-tomoderate” mental health services), may beprovided at a lower frequency/intensity thanwhat is typically provided in BHRS.
Some MCPs operate across multiple
counties, and others operate only in specificcounties. Ask your supervisor for an up-todate list of which MCPs operate in San
Mateo County.
Page 23 of 114

SUBSTANCE USE IDENTIFICATION AND SUD REFERRALSBHRS Documentation
Manual for SMHS

While the CalAIM Screening Tools are not specifically designed as an SUD screening tool, the CalAIM Screening Tools include
questions related to substance use disorder (SUD) that do not impact the screening score. If a beneficiary responds affirmatively
to an SUD question, the MCP or BHRS must offer them a referral for an SUD assessment in addition to completing the screening
tool and making an appropriate mental health delivery system referral.

Table of Contents

The person seeking care may decline the referral for an SUD assessment without any impact to their mental health delivery
system referral.

Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools
Diagnosis
Problem List

Staff should note that screening for SUD does not only occur during the administration of the Screening Tool. Substance use,
including nicotine/tobacco and caffeine, should be explored with all beneficiaries during the initial assessment and periodicallyduring the course of ongoing treatment.

Screening Tool Administration
WHO CAN ADMNISTER THE SCREENING TOOL?
The screening tools are designed to be administered by both non-clinicians and clinicians and do not require clinical judgment tocomplete. They may be administered in person, by telephone, or by video conference.
Within the BHRS System of Care, only staff in the BHRS Access Call Center are required to administer the Screening Tool. If abeneficiary is referred directly to a BHRS program or BHRS Contracted Agency, the Screening Tool process may be bypassed andthe individual may proceed to a full assessment to determine medical necessity without being required to complete theScreening Tool.

Care Planning
Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes

Access Call Center

County Program

Contracted Agency

AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions

WHERE SHOULD THE SCREENING TOOL BE DOCUMENTED?
Because the Screening Tool is to be administered prior to an individual being open to services, the Screening Tool should becompleted in an ICI episode in Avatar NX, and not a treatment program episode.

C – Progress Note Templates
Last Updated: 10/17/2024

Page 24 of 114

WHEN SHOULD THE SCREENING TOOL BE ADMINISTERED?

BHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment

 The Screening Tools for Medi-Cal Mental Health Services must be used by BHRS
when a beneficiary, or a person on behalf of a beneficiary under age 21, who is
not currently receiving mental health services, contacts the BHRS Access Call
Center seeking mental health services. The screening tool is not meant to be
used for determining if an existing beneficiary should step up or step downfrom current services.

 If a third party (including but not limited to a health care provider) simply

connects the beneficiary to the BHRS Access Call Center as a resource without
having conducted a screening or brief assessment to determine theappropriate delivery system for referral, the screening tool must be used.

 If a provider (e.g., a primary care physician, school nurse, case manager, etc.)
refers a beneficiary to the BHRS Access Call Center based on an understandingof the beneficiary’s needs, the screening tool is not required. In thesescenarios, BHRS and MCPs should follow existing protocols for provider
referrals and begin the assessment process.

“COLD” REFERRALSAND THESCREENING TOOL
“Cold” referrals are when thereferring provider suspects thatthe beneficiary might have a
behavioral health struggle but
did not assess the beneficiary’s
needs or appropriate level ortype of service, and might or
might not have even informed
the beneficiary of the referral. In
these cases, if BHRS Access Call
Center received the referral (alsoknown as a request for service),the screening tool must be
administered.

Problem List

 If a person seeking care contacts a BHRS County-Operated treatment program
directly or a BHRS County-Contracted provider directly, the screening tool is
not required and the provider may begin the assessment process and provide
services during the assessment period without using the screening tool(consistent with the No Wrong Door for Mental Health Services Policy).

Care Planning

WHEN TO RE-ADMINISTER THE SCREENING TOOL

Coordination of Care

The following describe when the screening tool must be re-administered.

Discharges and Transfers

One Year Rule

Coding Services

In most cases, a re-referred individual who is not currently receiving services from either the MCP or BHRS should be rescreened using the appropriate CalAIM Screening Tool if they meet either of these conditions:

Additional Assessment Tools
Diagnosis

Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

 The individual is requesting services after 365 days (1 year) of the administration of their most recent screening, OR
 The individual is requesting services after 365 days (1 year) of their last billable direct service.
Exception to this rule: If a returning individual had a Youth Screening Tool completed recently and are now of age for the Adult Screening Tool,
the Adult Screening Tool must be administered even if they are returning within a year of the administration of theYouth Screening Tool. This is because the Criteria for Access to SMHS for Youth and Adult are different.
Page 25 of 114

HOW TO ADMINISTER THE SCREENING TOOLBHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools
Diagnosis
Problem List
Care Planning
Coordination of Care
Discharges and Transfers

The specific wording and ordering of the questions /fields in the tools mustremain intact and the scoring methodology for the screening tools may
not be altered. Deviation from the specific wording of screening questions
is allowable as part of translation into another language if a translation is
not currently available – see DHCS website for links to currently available
translations of the Screening Tool
(https://www.dhcs.ca.gov/Pages/Screening-and-Transition-of-Care-Toolsfor-Medi-Cal-Mental-Health-Services.aspx). Additional translations may berequested through the BHRS Office of Diversity and Equity.

RELATED POLICIES TO REVIEWThe policy below is the main policy about the
Screening Tool.
Please note that there are additional policies notlisted below that may be related to a particular
population, program, or situation.
Policy 23-01: Adult and Youth Screening andTransition of Care Tools

The adult tool contains 14 questions, and the youth tool contains 23
questions. If a provider is conducting a screening with a person on behalfof a youth under age 21, the provider must use the “Respondent on Behalf of Youth” version of the tool. If a person responds
affirmatively to certain questions (e.g., emergency, suicidality, homicidality, already receiving mental health services from the
MCP or BHRS, certain youth access criteria), the screening must be discontinued, and the provider must complete appropriate
next steps as indicated in the tool.

Upon Completion of the CalAIM Screening Tool
Individuals must be referred to the appropriate Medi-Cal mental health delivery system (an MCP or BHRS) for a clinicalassessment based on their screening score. Once referred to the MCP or BHRS, the beneficiary will receive a clinical assessmentthat will determine the level of care and medically necessary services. The results of the screening tool do not guarantee thatthe system in which the beneficiary will receive the clinical assessment will be the system in which they will meet medical
necessity for ongoing treatment services. In some cases, a beneficiary might have been screened to complete the assessment in
one delivery system, but upon completion of the clinical assessment, it was determined they actually meet medical necessity forthe other delivery system.

Coding Services

WHAT IF THE BENEFICIARY DECLINES REFERRAL TO MCP

Progress Notes

If a beneficiary receives a screening in one delivery system but declines the referral to the other delivery system forassessment, the delivery system that administered the screening must provide an assessment. MCPs and BHRS can receive
reimbursement for assessment and clinically appropriate services during the assessment period, regardless of whether theassessment results in the beneficiary meeting access criteria.

AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

WHAT IF THE BENEFICIARY IS NOT ENROLLED IN THE MCP
If a beneficiary’s screening score requires a referral to an MCP but the beneficiary is not enrolled in an MCP, BHRS must
provide an assessment or facilitate enrollment in an MCP and coordinate the Medi-Cal member's referral to ensure a timely
clinical assessment.
Page 26 of 114

ICC Eligibility Screening Tool
BHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment

BackgroundAs a result of the Settlement Agreement in Katie A. v. Bontá (2002), theState of California agreed to take a series of actions that transformed theway California children and youth who are in foster care, or who are at
imminent risk of foster care placement, receive access to mental healthservices. The settlement specifically changed the way a defined group ofchildren and youth with the most intensive needs, referred to as “Katie A.
subclass members”, are assessed for mental health services.
Pursuant to the settlement, beginning in 2013, subclass members wererequired to be provided an array of services, and specifically medicallynecessary ICC, IHBS, and TFC, consistent with the Core Practice Model(CPM).

RELATED POLICIES TO REVIEWThe policy below is the main policy that includes
information about ICC, IHBS, and TFC Services.
Please note that there are additional policies notlisted below that may be related to a particular
population, program, or situation.
Policy 20-04: Authorization of Youth Specialty
Mental Health Services (SMHS)

Diagnosis

While the Katie A. Settlement only concerned children and youth in foster care, or at imminent risk of placement in foster care,
this was changed in 2017 when membership in the Katie A. class or subclass ceased to be a requirement for receiving medicallynecessary ICC, IHBS, and TFC. Therefore, a child or youth need not have an open child welfare services case to be considered
for receipt of ICC, IHBS, or TFC.

Problem List

ICC must be provided to all children and youth who meet medical necessity criteria for those services.

Additional Assessment Tools

Care Planning
Coordination of Care

Eligibility for ICC Services

Discharges and Transfers

ICC is provided through the EPSDT benefit to all children and youth who:

Coding Services

 Are under the age of 21;

Progress Notes

 Are eligible for the full scope of Medi-Cal services; andAppendices Meet medical necessity criteria for SMHS.

A – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

ICC is intended to link beneficiaries to services provided by other child-serving systems; to facilitate teaming; and to coordinate
mental health care. If a beneficiary is involved with two or more child-serving systems, the child should be getting ICC, and the
MHP should utilize ICC to facilitate cross-system communication and planning. Children and youth receiving SMHS, who also are
involved with the child welfare system, special education, juvenile probation, drug and alcohol, and other health and humanPage 27 of 114

services agencies or legal systems, should have improved outcomes from receiving ICC. These examples illustrate various childserving agencies that may be involved in a child’s or youth’s care, and result in a need for ICC, but are not an exhaustive list.

BHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity

Eligibility Process within BHRS
MHPs must make individualized determinations of each child’s/youth’s need for ICC, based on the child’s/youth’s strengths andneeds. These services are appropriate for children and youth with more intensive needs who are in, or at risk of, placement inresidential or hospital settings, but could be effectively served in the home and community.
BHRS has developed the “ICC Eligibility Screening Tool” to support staff in making determination of if children and youth whomeet medical necessity criteria need ICC.
The ICC Eligibility Screening Tool is required to be used for all beneficiaries 20 years old and under at admission and whenever
there is a clinically significant change for as long as the beneficiary is under 21 years of age.

Screening Tools
Assessment
Additional Assessment Tools
Diagnosis
Problem List

At
Admission*

Care Planning
Coordination of Care
Discharges and Transfers
Coding Services

And whenever there is a clinically significant change.

*Must be completed within approximately 60 days of admission.

Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

Page 28 of 114

ASSESSMENTBHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance

A Mental Health Assessment is the foundation of any individual’s Mental Health treatment. It is the process by which providers
develop a clinical understanding regarding an individual’s needs, determines an accurate diagnosis, confirms the appropriate
treating system, and what services are medically necessary to support the person in their goals so they can thrive in theircommunity.
In order to ensure that an assessment current, accurate, andrespectfully represents that beneficiary’s perspective, the following
applies to all assessments:

Documentation Requirements

 The assessment cannot be solely based on history or chart

Access to SMHS and Medical
Necessity The person conducting the assessment must have direct

Screening Tools
Assessment
Additional Assessment Tools
Diagnosis
Problem List
Care Planning
Coordination of Care
Discharges and Transfers

review.

contact with the beneficiary (either via video, phone, or inperson).

 Assessment appointments may occur remotely; however
you should have at least one face-to-face appointment(either by video or in-person) before finalizing theassessment.

RELATED POLICIES TO REVIEW
There are many policies in BHRS related to theproviding remote services.
Please note that there are additional policies notlisted below that may be related to a particular
population, program, or situation.
Policy 22-06: Electronic Communication (General
Guidelines) [Update In Progress]
Policy 22-07: Electronic Communication (forCommunication with Clients) [Update In Progress]

DHCS does allow for Specialty Mental Health Assessments to be completed with only synchronous audio-only communication(e.g., non-video phone calls), but does not mandate that MHPs allow all assessments to be completed using synchronous audioonly communication. The decision to complete an assessment using only audio-only communication with the beneficiary is aclinical and programmatic decision. Staff should consult with their supervisor to determine if it is clinically appropriate andallowable under their program to finalize an assessment if all contact with the beneficiary was through synchronous audio-onlycommunication.

Coding Services
Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix

Required to Finalize Initial Assessment•At least one Face-to-Face interaction, either
through video or in-person

Needs Approval to Finalize Initial Assessment•No Face-To-Face Interaction, meaning allcommunication with beneficary was audio-only.

B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

Page 29 of 114

Scope of Practice
BHRS Documentation
Manual for SMHS
Table of Contents
Introduction

The diagnosis, mental status exam, medication history, and assessment of relevant conditions and psychosocial factors affecting
the beneficiary’s physical and mental health must be completed by a provider operating in their scope of practice under
California State law. The provider must be licensed, waivered, and/or under the direction of an authorized LMHP.
For example, a mental health diagnosis and the mental status exam (MSE) can only be provided by a Licensed Mental HealthProfessional (LMHP)/Licensed Professional of Healing Arts (LPHA) for whom these activities are part of their scope of practice.
Within BHRS, this includes:

Compliance Physician (MD)Documentation Requirements

 Licensed/waivered Psychologist

Access to SMHS and Medical
Necessity Licensed/registered Clinical Social Worker

RELATED POLICIES TO REVIEWThe policy below provides information on Scopeof Practice as it relates to documentation.

Screening Tools

 Licensed/Registered Marriage and Family Therapist,
Licensed/Registered Licensed Professional Clinical Counselor

Please note that there are additional policies notlisted below that may be related to a particular
staff classification, program, or situation.

Assessment

 Registered Nurse (RN) with a Master’s degree in Psychology

Policy 93-10: Practice Standards

Additional Assessment Tools

 Nurse Practitioner (NP) licensed in a mental health‐related field

Diagnosis
Problem List
Care Planning
Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix

The LPHA will sign as the “assessor” on the signature page of assessment forms used by BHRS. At a minimum, the assessor is
responsible for reviewing and agreeing with the completed assessment, conducting the mental status exam, and providing aclinical formulation and the diagnosis.

Additional Staff Who May Contribute to the Assessment
Certain other qualified providers may complete parts of an assessment, including gathering the beneficiary’s mental health andmedical history, substance exposure and use, and identifying strengths, risks and barriers to achieving goals. These staff may
contribute to and conduct all other portions of the assessment and will sign the assessment form as “authorized clinical staff.”
Please see the Scope of Practice Matrix for up-to-date list of what functions certain qualified positions are able to complete as it
relates to clinical documentation (e.g., assessment, care planning).
Clinical trainees may sign an assessment as “authorized clinical staff” and may provide a diagnosis and mental status exam as
long as it is within the scope of practice of their discipline and they are operating under the supervision of a licensed clinician(LMHP/LPHA) in one of the disciplines noted above. The supervisor must then sign the assessment as the “assessor.”

B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

Page 30 of 114

Assessment Domains
BHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools
Diagnosis
Problem List
Care Planning
Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

The assessment contains a standard set of Assessment domains required by DHCS that should not vary from provider toprovider. Below is information on the standardized domains comprising the assessment for understanding the person’s careneeds. While each of the domains are required and must be addressed, information may overlap across domains. When
conducting an assessment, it is important to keep in mind the flow of information and avoid duplication to ensure that a clear
and ideally chronological account of the person’s current and historical need is accurately documented.
Below are the domain categories, key elements, and guidance on information to consider under each domain. The informationin the outline below is not meant to be an exhaustive list. The practitioner should always consider the person within the context
of their developmental growth and their larger community, including cultural norms or expectations when completing anddocumenting an assessment. Information within the assessment should come from the person seeking care, in their own words
whenever possible. For children/youth and those with disabling impairments, this may also include information from collateralsources. Please note that these are general descriptions of required content for the assessment.
Please also note that the actual BHRS Assessment Form may have certain sections broken down into sub-categories or include
other data collection or required elements that are mandated outside of the CalAIM documentation requirements.
Note for contract agencies: If you have an assessment form in your own EHR, your assessment does not have to exactly matchthe BHRS format. The assessment may be in any format so long as the assessment domains and components are included, andthe assessment information is comprehensive, consolidated, and can be produced and shared as appropriate to support
coordinated care, in accordance with applicable state and federal privacy laws. To the extent the information is available, allcomponents listed within each of the seven domains shall be included as part of a comprehensive assessment.

Domain 1
Domain 1 focuses on the main reason the person is seeking care, in their own words if appropriate. The goal is to document an
account of what led up to seeking care. This domain addresses both their current and historical states related to the chiefcomplaint.
 Presenting Problem(s) – The person’s and collateral sources’ descriptions of problem(s), impact of problem on person incare. Descriptions should include, when possible, the duration, severity, context and cultural understanding of the chiefcomplaint and its impact.
 History of Presenting Problem(s) – Describe progression/course of the beneficiary’s current presenting problem, including
how the beneficiary has been impacted historically by the problem, if/how the severity/frequency of the problem haschanged over time, and what barriers/resources may have helped or further impaired the beneficiary’s functioning in
relation to the problem.
 Member-Identified Impairment(s) – The person and collateral sources identify the impact/impairment – level of distress,
disability, or dysfunction in one or more important areas of life functioning as well as protective factors related toPage 31 of 114

functioning. Functioning should be considered in a variety of settings, including at home, in the community, at school, atwork and with friends or family.

BHRS Documentation
Manual for SMHS

 Current Mental Status (Mental Status Exam) – The person’s mental state at the time of the assessment. This can be in theform of an informal or formal Mental Status Exam, to be completed by an LPHA.


An informal Mental Status Exam (MSE) includes observing the beneficiary’s functioning at the time you areassessing the beneficiary, and using their responses and behaviors to determine their mental status at that point intime. The mental status exam does not need to be a formal MSE. While the client’s mental status should be
examined and documented, a formal mental status exam is not required to finalize the Assessment.



A formal Mental Status Exam (MSE) (either full MSE or mini MSE) includes using standard techniques to, forinstance, assess a beneficiary’s long-term and short-term memory; orienting the beneficiary to person, place, andtime; and conducting the serial 7s. A formal MSE is not required in order to finalize an assessment. However, thosetrained in conducting a formal MSE may conduct a formal MSE and document it in the beneficiary’s assessment.

Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools
Diagnosis
Problem List
Care Planning
Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates

BHRS Documentation
Manual for
LastSMHS
Updated: 10/17/2024

Domain 2
Domain 2 involves information on traumatic incidents, the reactions of the person in care to trauma exposures and the impactof trauma on the presenting problem. It is important that traumatic experiences are acknowledged and integrated into thenarrative. Take your cues from the person in care — it is not necessary in every setting to document the details of traumatic
incidents in depth.
 Trauma Exposures – A description of psychological, emotional responses and symptoms to one or more life events that are
deeply distressing or disturbing. This can include stressors due to significant life events (being unhoused or insufficiently
housed, justice involvement, involvement with child welfare system, loss, adverse childhood events, etc.)
 Trauma Reactions – The person’s reaction to stressful situations (i.e., avoidance of feelings, irritability, interpersonal
problems, etc.) and/or information on the impact of trauma exposure/history to well-being, developmental progression
and/or risk behaviors.

Domain 3
Domain 3 focuses on the person in care’s history of behavioral health needs and the interventions that have been received toaddress those needs. Domain 3 also includes a review of substance use/abuse to identify co-occurring conditions and/or the
impact of substance use/abuse on the presenting problem.
 Behavioral Health HistoryMental Health History – Review of acute or chronic conditions not earlier described. Mental health conditions
previously diagnosed or suspected should be included. Include information regarding any past mental healthtreatment.
Page 32 of 114



BHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools
Diagnosis
Problem List
Care Planning
Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

Co-Occurring Substance Use – Review of past/present use of substances, including type, method, and frequency ofuse. Substance use conditions previously diagnosed or suspected should be included. Co-occurring disorders that are
not related to Substance Use should be inputted in Domain 4. Include information regarding any past SUD
treatment.

 Previous Behavioral Health Services – Review of previous treatment received for mental health and/or substance abuseconcerns, including providers, therapeutic modality (e.g., medications, therapy, rehabilitation, hospitalizations, crisis
services, substance abuse groups, detox programs, Medication for Addiction Treatment [MAT], length and/or dates oftreatment, and efficacy/response to interventions.)

Domain 4
Domain 4 integrates medical and medication items into the psychosocial assessment. The intersection of behavioral healthneeds, physical health conditions, developmental history, and medication usage provides an important context forunderstanding the needs of the people we serve.
 Co-occurring Medical Conditions (other than substance use) – This includes physical, neurological, developmental, etc.
conditions but does not include substance use issues/conditions. For example, you would include in this section prenatal andperinatal events and relevant or significant developmental history, if known and available (primarily for beneficiaries 21
years old or younger). Be sure to include information about treatment history (medications, treating providers, etc.) related
to the co-occurring medical condition. Co-occurring substance use would be inputted in Domain 3.
 Medical History – Relevant past medical conditions (that were not included in the co-occurring medical conditions section),including the treatment history of those conditions.
 Current and Past Medications – Current and past medications, including the prescribing clinician, reason for medication
usage, dosage, frequency, adherence, and efficacy/benefits of medications. When available, the start and end dates orapproximate time frames for medication should be included.

Domain 5
Domain 5 supports clinicians in understanding the environment in which the person in care is functioning. This environment canbe on the micro-level (e.g., family) and on the macro-level (e.g., systemic racism and broad cultural factors).
 Social and Life Circumstances – Current living situation, daily activities, social supports/networks, legal/justice involvement,
military history, community engagement, description of how the person interacts with others and in relationship with thelarger social community.
 Culture/Religion/Spirituality – Cultural factors, linguistic factors, SOGIE (Sexual Orientation, Gender Identity andExpression), and/or Black, Indigenous and People of Color (BIPOC) identities, spirituality and/or religious beliefs, values, andpractices Family – Family history, current family involvement, significant life events within the family (e.g., loss, divorce, births).
Page 33 of 114

Domain 6
BHRS Documentation
Manual for SMHS
Table of Contents

Domain 6 explores areas of risk for the beneficiaries we serve, but also the protective factors and strengths that are an equallyimportant part of the clinical picture. Clinicians should explore specific strengths and protective factors and understand how
these strengths mitigate risks that the beneficiary is experiencing.
 Strengths and Protective Factors – Personal motivations, desires and drives, hobbies and interests, positive savoring andcoping skills, availability of resources, opportunities and supports, interpersonal relationships.

Documentation Requirements

 Risk Factors and Behaviors – Behaviors that put the person in care at risk for danger to themselves or others, including
suicidal ideation/planning/intent, homicidal ideation/planning/intent, aggression, inability to care for self, recklessness, etc.
Include triggers or situations that may result in risk behaviors. Include history of previous attempts, context for risk
behaviors (e.g., loneliness, gang affiliations, psychosis, drug use/abuse). May include specific risk screening/assessment tools(e.g., Columbia Suicide Severity Rating Scale) and the results of such tools used.

Access to SMHS and Medical
Necessity

Domain 7

Introduction
Compliance

Screening Tools
Assessment
Additional Assessment Tools
Diagnosis
Problem List
Care Planning
Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes
AppendicesDomain 7 provides clinicians an opportunity to clearly articulate a working theory about how the person in care’s presenting
challenges are informed by the other areas explored in the assessment and how treatment should proceed based on thishypothesis. This section must be completed by an LPHA.
 Diagnostic Impression – Clinical impression, including any current medical diagnoses and/or diagnostic uncertainty (ruleouts, provisional or unspecified diagnoses)
 Medical Necessity Determination/LOC/Access Criteria – Summary of medical necessity determination, including if
beneficiary meets criteria for SMI services through BHRS, or will be transferred to another system of care (for instance, the
MCP for mild-to-moderate services).
 Treatment Recommendations – Recommendations for detailed and specific interventions and service types based onclinical impression and overall goals for care.
 Clinical Formulation /Summary – Summary of clinical symptoms supporting diagnosis, functional impairments (clearly
connected to symptoms/presenting problem), history, mental status exam, cultural factors, strengths/protective factors,
risks, and any hypothesis regarding predisposing, precipitating and/or perpetuating factors to inform the problem list (to be
explained further below)

A – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

Page 34 of 114

Additional Assessment Components
BHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools
Diagnosis

Evidence Based Practices
An Evidence-Based Practice (EBP) is an intervention that has a strongly rooted scientific foundation that has been demonstrated
to be effective when implemented to fidelity.
DHCS collects data on select Evidence Based Practices (EBP) that are being utilized for beneficiaries. The following list includes
EBPS that DHCS is gathering data on. Staff may use other EBPs in their practice that are not listed below. However, if any of
the EBPs from the list below are being utilized with a particular beneficiary, staff should mark the appropriate EBPs in theassessment.
☐ Assertive Community Treatment☐ Illness Management and Recovery☐ Supportive Housing☐ New Generation Medications☐ Supportive Employment☐ Family Psychoeducation☐ Integrated Dual Diagnosis
Treatment☐ Medication Management☐ Functional Family Therapy☐ Unknown Evidence-Based
Practice/Service Strategy☐ Therapeutic Foster Care
☐ Multisystemic Therapy

Problem List

Assessment Service Strategies

Care Planning

Broad categories describing an underlying concept or fundamental approach by a team or program. A service strategy will bechecked as part of a beneficiary’s Assessment when it is anticipated to be a part of the core services provided to the beneficiary.
These strategies are a broader category of strategies that will be used to address the items on the beneficiary’s problem list
and/or entered into a treatment plan. For more information on services/interventions that would require a formal treatment
plan, see the Care Planning section.

Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

 Peer/Family Delivered – Services provided by beneficiaries or family members (of someone who has behavioral healthconditions) who are hired as program staff.
 Psycho‐Education – Services providing education regarding diagnosis, assessment, medication, supports, and treatments.
 Family Support – Services provided to beneficiary’s family members in support of the beneficiary.
 Supportive Education – Services supporting a beneficiary to achieve educational goals with the aim of productive work andself‐support.
Page 35 of 114

BHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools
Diagnosis
Problem List
Care Planning
Coordination of Care
Discharges and Transfers
Coding Services

 Delivered in Partnership with Law Enforcement – Services
integrated or coordinated with law enforcement, probation or
courts (e.g., mental health court, diversion) to provide alternatives
to incarceration.
 Delivered in Partnership with Health Care – Services integrated orcoordinated with physical health care, including co‐location orcollaboration with providers and sites offering physical health care.
 Delivered in Partnership with Social Services – Services integrated
or coordinated with social services, including co‐location orcollaboration with providers and sites offering social services.
 Delivered in Partnership with Substance Abuse Services – Services
integrated or coordinated with substance abuse services, including
co‐location or collaboration with providers and sites offering
substance abuse services. (Does not include substance abuse
services provided by County staff.)

WHERE DO I DOCUMENT MORE
SPECIFIC STRATEGIES?
While “Service Strategies” that are included in
the assessment are broad categories ofservices, more specific services and strategies
within these broad categories may be
identified and described in otherdocumentation, such as a written care plan.
Specific strategies that may fall within one of
the broad “Service Strategy” categories
include, but are not limited to, Parenting
Groups, CFTs, Rehab Services, CollateralServices, etc.

 Integrated Services for MH & Aging – Services integrated or coordinated with issues related to aging, including co‐locationor collaboration with providers and sites offering aging‐related services.
 Integrated Services for MH & Developmental Disability ‐ Services integrated or coordinated with services fordevelopmental disability, including colocation or collaboration with providers and sites offering services for beneficiaries
with developmental disabilities.
 Ethnic‐Specific Service Strategy – Culturally appropriate services tailored to persons of diverse cultures. Can include ethnic‐
specific strategies and practices such as traditional practitioners, natural healing, and recognized community ceremonies.
 Age‐Specific Service Strategy – Age‐appropriate services tailored to specific age groups. These services should promote awellness philosophy including concepts of recovery and resiliency.

Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

Page 36 of 114

Assessment Types
BHRS Documentation
Manual for SMHS
Table of Contents

There are several types of Assessments used in BHRS. It is important to select the correct assessment type to ensure that you aremeeting documentation requirements. An assessment is considered completed on the date the LPHA signs and submits it as
final. Quality Management may approve alternate assessment forms for use in certain situations.

INITIAL ASSESSMENT TYPES

Introduction

1) Initial Assessment (Clinician, Case Manager)

Compliance2) Initial Assessment – Prenatal to Three Assessment (only available in
Youth Assessment Form) – only to be used by staff in the Prenatal toThree programs.

Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools
Diagnosis
Problem List
Care Planning
Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

3) Initial Assessment – School Based Mental Health (only available in
Youth Assessment Form) – only to be used by staff in the School-Based
Mental Health Program.

OTHER ASSESSMENT TYPES
1) Reassessment2) Update Assessment

WHICH ASSESSMENT TYPESQUALIFY AS COMPLETE
MEDI-CAL ASSESSMENTS?
Only the Initial Assessment Types andthe Reassessment Type may be used tofulfill the requirement for a complete
Medi-Cal Assessment. However, even if
these forms are used, the informationmust be sufficiently complete to meet fullcriteria for a complete Medi-Cal
Assessment.

3) Assessment Review Progress Note (using standard progress note)

Initial Assessment
Resets the Assessment Timeline: YES
Initial Assessments must be completed for beneficiaries who are new to the
BHRS SMHS system of care. Beneficiaries are considered “new” when they
are not already connected to a BHRS Specialty Mental Health Program(including contract agencies) at the time of the assessment. If the individual isconnected a BHRS that does not complete SMHS assessments and does notprovide SMHS (for instance, they are open for SUD services but not MH
services), then they would be considered “new” to the BHRS SMHS.
“New” beneficiaries may also include beneficiaries who had previously beendischarged from a BHRS program or one of its contracted agencies and is now
returning for services, or who are enrolled in a program but had an extended
period without services.

WHAT ABOUT RETURNING
BENEFICIARIES?
Be sure to use clinical judgment, consult
with supervisors, and reference relevant
policies to determine whether or not an
initial assessment or reassessment isappropriate for these “returning”
beneficiaries.

Page 37 of 114

Reassessment
BHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools
Diagnosis
Problem List
Care Planning
Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

Resets the Assessment Timeline: YES
Use the reassessment form any time there is a significant change in level of care, disruption of services (extended absence fromservices or if returning after having been discharged), any major psychosocial events, or whenever a beneficiary needs to bereevaluated to determine if they still meet criteria to access medically necessary services. This is the main Assessment type used
to document reassessments for beneficiaries with ongoing services (with no lapse of services over 180 days).
All treatment programs are responsible for ensuring that the client’s record includes a complete Medi-Cal assessment meeting
all requirements even if the program is not considered the lead/care coordinating team/episode. It is not sufficient to state “nochange,” “see progress notes,” or “see previous assessment.”

Update Assessment
Resets the Assessment Timeline: NO
Use this form to provide updates to specific sections of the assessment or when
you need to update information in the assessment to substantiate an update
made to the client’s diagnosis (in Avatar NX, the updated diagnosis itself would
be entered into the Diagnosis Form that is part of the Assessment Bundle).
This form may be completed when additional assessment information isgathered or a change occurs after the completion of the Initial Assessment, or
between required assessments. You may add information to existing, specificsections of the assessment.

DIAGNOSIS UPDATESWhen updating diagnosis information,use your clinical judgment to determine
whether or not the diagnosis update issignificant enough to warrant a fullReassessment rather than an Update
Assessment.

Assessment Review Progress Note
Resets the Assessment Timeline: NO
This is a standard progress note that documents that a review of the most recent assessment occurred and the outcome of that
review. You do not need to also complete a formal Assessment form if the outcome of your assessment review resulted in a
determination that all information in the assessment continues to be relevant and, therefore, a Reassessment Form or Update
Assessment Form do not need to be completed.
An Assessment Review Progress Note is NOT sufficient to document updates to the assessment or when a beneficiary is
returning to services after 180 days of their last billable date. Additionally, a progress note is NOT sufficient for new beneficiaries
or for beneficiaries for whom a reassessment is due (e.g., it has been over 3 years since their last assessment).
In cases where an assessment review resulted in assessment information needing to be updated, you must document those
updates using one of the Assessment Forms listed above.
Page 38 of 114

A Note About Incomplete Assessments
BHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools

There are a number of reasons why the assessment process might begin but will
not result in a completed assessment. For example, an individual might be lost tofollow up or might change their mind in the middle of the assessment about
wanting services.
Clinicians may finalize the assessment based on the type of the assessment thatthey had originally intended to complete (e.g., initial assessment orreassessment). However, they should indicate in each required field for which
information was unable to be gathered that they were unable to assess theindividual in that area. The clinical formulation should also indicate that a fullclinical formulation was not able to be completed and that the individual should
be reassessed should they return for services.
If the individual returns to BHRS to re-request services, it is the responsibility of
the next clinical team to read the full assessment and ensure that thebeneficiary’s assessment is up-to-date and accurate. It is not sufficient to solely
use the date of the last assessment to determine if a previously submitted initialor re-assessment is complete.

Importance of Reading theMost Recent Assessment
A due date reminder or a finalization
date for the last assessment does
not indicate that the most recent
assessment met all requirements tobe considered a complete Medi-Cal
Assessment.
Rather than determining if a newassessment is needed based on thedate of the most recent assessment,
staff should review the full contentsof the most recent assessment.

Diagnosis
Problem List
Care Planning
Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

Page 39 of 114

Assessment Timelines
BHRS Documentation
Manual for SMHS

Initial Assessment Timeline

Table of Contents

60

Introduction

Days

Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools
Diagnosis
Problem List
Care Planning
Coordination of Care
Discharges and Transfers
Coding Services

An assessment may exceed the 60 day guideline in cases in which, for instance, the beneficiary’s presentation is complex andrequires a longer time to assess then expected, appointments had to be rescheduled multiple times, or the beneficiary does nothave a reliable mode of communication to facilitate timely scheduling. If an assessment is not able to be finalized within 60 days,
the reasons for the delay and any attempts to contact the beneficiary to complete the assessment should be documented inprogress notes and staff may continue to take the time needed to develop a complete assessment.

Reassessment Timeline for Beneficiaries with Ongoing Services
Under CalAIM, DHCS no longer specifies a timeframe by which reassessment must be completed. However, a reassessment
continues to be required at clinically appropriate and generally accepted time frames to best support the beneficiary’s needs
and goals. Generally accepted timeframes for completion of the assessment is every 3 years, or sooner if clinically indicated.
If, after 3 years, it is determined that there has been no changes to the individuals’ circumstances, level of functioning, diagnosis,
or other areas that would point to the need for a reassessment, then staff should consult with their supervisor if the individual
continues to be best served with the current level of care or if a different level of care or the addition or removal of services areindicated. For example, a lack of change in the beneficiary’s functioning after three years since the last assessment may point to:•a level of stability that would indicate the need for a transition to a lower level ofcare•

the need for a higher level of care to better support the individual’s progress on
goals

•

the need for additional services within the current level of care to better support
the individual’s progress on goals•

the removal of certain ancillary services that are no longer necessary within thecurrent level of care

Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

Under CalAIM, there is more flexibility with the amount of time that it takes to complete anassessment. This is because DHCS no longer specifies a timeframe by which initial assessments must
be completed. However, the time it takes to complete an assessment should be reasonable andclinically appropriate. Generally accepted timeframe for completion of the assessment is within 60
days of admission. Therefore, staff should aim to complete initial assessments within this generally
accepted timeframe.

Last
Assessment

Next
Assessment

3
Years

Page 40 of 114

Assessment /Reassessment Timelines for Returning Beneficiaries
BHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools
Diagnosis
Problem List
Care Planning
Coordination of Care
Discharges and Transfers
Coding Services

Assessment completion timelines for returning beneficiaries depends on a number of circumstances and clinical considerations.
The next few subsections explain some of the key considerations and guidelines for completing assessment for returningbeneficiaries.

RE-OPENING AN EPISODE
Decisions about whether or not to re-open a recently closed
episode or open a new episode for returning beneficiaries
should include but is not limited to the following:•

Review of beneficiary’s most recent assessment•

Internal program/team protocol•

Clinical judgement and Supervisor consultation•

BHRS Policies

All re-openings must include a progress note that specifies
that the client returned to service after an extended
absence, noting the last date of billable service. Progressnote should also include information about whether or nota reassessment was completed.

A – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

There are many policies in BHRS related to the
opening/closing of beneficiaries in different circumstances.
For example, the following two policies are related to closureof cases.
Please note that there are additional policies not listed belowthat may be related to a particular population, program, or
situation.
Policy 16-01: Review and Closure of Inactive Mental Health
Treatment Cases [Update In Progress]
Policy 97-11: Absence from the State for More than 60 Days

DETERMINING THE TYPE OF REASSESSMENT
In addition to the above, when determining whether or not a
new assessment, reassessment, or update assessment should
be completed for returning beneficiaries, information toconsider includes but it not limited to:•

The last date that the beneficiary was provided abillable service.

•

Reasons client was previously discharged and when
they were discharged.

•

Any significant events or changes that may havechanged the clinical assessment and level offunctioning for the beneficiary as compared to thelast completed assessment.

Progress Notes
Appendices

RELATED POLICIES TO REVIEWDOCUMENTATION REMINDER
You may consider an assessment complete if you havethe minimum required elements of an assessment andare able to determine medical necessity.
Remember, in the event that you receive additional
information that is important to add to the assessment,
you always have the option to add information to theassessment after you finalize, either through a
Reassessment or Update Assessment form.

Page 41 of 114

ALLOWABLE ASSESSMENT TYPES BASED ON LENGTH OF ABSENCE FROM SERVICESBHRS Documentation
Manual for SMHS

Determining what type of assessment documentation needs to be done for returning beneficiaries depends on several factors.
The following table provides guidelines to assist staff in determining the type of assessment that may be completed for a
returning beneficiary. Timeframes to keep in mind are 180 Days and 360 Days from the date of the last billable service.

Table of Contents
Introduction

0-180 Days

181-360 Days

Compliance Initial Assessment Form

 Initial Assessment Form

Documentation Requirements

 Reassessment Form

 Reassessment Form

Access to SMHS and Medical
Necessity

 Update Assessment

Screening Tools

361 and over Days
 Initial Assessment Form Assessment Review
Progress Note

Assessment
Additional Assessment Tools
Diagnosis

0-180 DAYS (INCLUSIVE OF 180TH DAY)
If the beneficiary was discharged and returned to services within 180 days of the last date of billable service.

Problem List
Care Planning
Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix

Depending on the circumstances of the beneficiary, the clinician should use
their clinical judgment in consultation with their supervisor to determine if
the beneficiary should be reopened to the most recent episode for that
program. If appropriate, the clinician may resume services in the most recent
episode by having the program admin back out the discharge date.
The clinical team has some flexibly here to determine the level ofreassessment needed. Clinicians may either do a reassessment, update
assessment, or, if no there was no change in circumstance since the lastassessment was completed, a progress note documenting the assessment
review may be completed. An assessment review note documents that themost recent assessment was reviewed and that the information continues tobe up-to-date (this note does not restart the assessment timeline).

DOCUMENTATION REMINDER
If the clinician determines that thebeneficiary will be opened to a new
episode, and the beneficiary will bereceiving services that require a care plan
progress note or formal care plan, thesewill need to be re-done in the new episode.

B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

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181-360 DAYS (INCLUSIVE OF 360TH DAY)BHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools
Diagnosis
Problem List
Care Planning
Coordination of Care

If the beneficiary was discharged and returned to services between 181 days – 360 days of the last date of billable service.
The clinical team has some flexibly here to determine the level ofreassessment needed based on the beneficiary’s level of functioning andlife circumstances. However, there is not as much flexibility as the 0-180
day scenario with regards to the type of assessment that must becompleted.
For returns to service between 181-360 days of the last billable service, areassessment is required. This reassessment may be done in the form of
an initial assessment, reassessment, or Update Assessment, dependingon the situation.
An Assessment Review Progress Note is not sufficient for beneficiaries
who return to service over 180 days since their last date of billable
service.

DOCUMENTATION REMINDER
Beneficiaries who return to services within 180
days may be reopened to the previous episode
ONLY if they meet criteria outlined in Policy 1601: Review and Closure of Inactive Mental Health
Treatment Cases.
Beneficiaries who do not meet criteria outlined in
Policy 16-01 must be opened to a new episode.

361 AND OVER DAYS
If the beneficiary was discharged and returned to services more than 360 days of the last date of billable service.
If a beneficiary is discharged and returns to care after 360 days (1 year): The treatment team should complete an Initial
Assessment. The information from the previous assessment may be pulled into the new assessment, then update theinformation as needed.
If the beneficiary is going to be evaluated by the physician, the physician’s evaluation must be documented in either anassessment form or in a PIN progress note. Whether or not a PIN progress note is sufficient depends on if there is also a current
and valid Medi-Cal Assessment in place.

Discharges and Transfers
Coding Services
Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

Page 43 of 114

Multiple Teams or Providers for A Single Beneficiary
BHRS Documentation
Manual for SMHS

Physician Initial Assessment and Physician Initial Note (PIN):

Table of Contents

For some teams, both the clinician and the MD will conduct an assessment. However, the form that is used to document theassessment in the chart determines which assessment to use as the beneficiary’s “official” Medi-Cal assessment. While clinicians
primarily use the Assessment form, MDs vary from documenting the assessment in the assessment form or documenting theassessment in a progress note (a.k.a. “Physician Initial Note” or “PIN”) only.

Introduction
Compliance•

If there is a current and valid Medi-Cal Assessment in place, the Physician Initial Progress Note (PIN) – which iscompleted in the “Mental Health Progress Note” in Avatar – should at least be reviewed and the MD/NP should write a
progress note stating they reviewed the previous Physician’s PIN progress note and document if there are any changes
in their progress note.

•

If there is no current and valid Medi-Cal Assessment in place, then the treatment team should determine who willcomplete the formal reassessment. If the clinician will be completing a formal Medi-Cal Assessment, then MD/NP
should complete a PIN note to document their reassessment. Otherwise, the MD/NP should complete a formal MediCal Assessment.

Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools
Diagnosis
Problem List
Care Planning
Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix

Multiple Teams
When two or more treatment teams are treating the same beneficiary, the teams should
coordinate care and determine which team will be the lead in developing and completing theassessment. However, it is every team’s responsibility to ensure that there is a complete andcurrent assessment that meets requirements for any beneficiary enrolled in their program.
For example, If the beneficiary is already open to a treatment program and an additional teamwill be added to co-support the beneficiary, each team is responsible for ensuring that there isa current and accurate assessment in the clinical record. Additionally, if an assessment has notbeen updated for quite some time (beyond generally accepted practice or long after asignificant change occurred), teams should communicate with each other regarding the lapse
and actively coordinate to complete a current assessment.
Remember, not only should active communication and coordination between teams sharing a beneficiary occur, it should also
be documented in a progress note.

B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

Page 44 of 114

ADDITIONAL REQUIRED ASSESSMENT TOOLSBHRS Documentation
Manual for SMHSCANS and PSC-35

Table of Contents

CHILD AND ADOLESCENT NEEDS AND STRENGTHS (CANS)

Introduction

The CANS is a structured assessment used for identifying
youth and family actionable needs and useful strengths. It
provides a framework for developing and communicating
about a shared vision and uses youth and family
information to inform planning, support decisions, andmonitor outcomes. Clinical staff will complete the CANS
through a collaborative process which includes, at aminimum, children and youth, ages 6 to age 20, and theircaregivers.

Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools
Diagnosis
Problem List
Care Planning
Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

RELATED POLICIES TO REVIEWThe following Memo is the primary guidance in BHRS
regarding the CANS and PSC-35.
Please note that there are additional policies not listed
below that may be related to a particular population,
program, or situation.
Memo 01-22: CANS and PSC-35 – All Providers

PEDIATRIC SYMPTOM CHECKLIST (PSC-35)
The PSC-35 is a psychosocial screening tool designed tofacilitate the recognition of cognitive, emotional andbehavioral problems so that appropriate interventions may
be initiated as early as possible. Parents/caregivers willcomplete PSC-35 (parent/caregiver version) for children andyouth ages 3 to age 18. For the PSC-35, if the child/youth
does not have a parent/caregiver or the parent/caregiver
declines, then staff will document this in their progress
notes.
The PSC-35 can be found in Avatar utilizing the “Generic
Access” Widget. Instructions on how to add the PSC-35
widget and PDF versions of the forms are available here:
https://www.smchealth.org/bhrs-policies/cans-child-andadolescent-needs-and-strengths-psc-35. If using the PDF
version of the PSC-35, please make sure the completed PSC35 forms are also scanned into the beneficiary’s medical
record.

AGE RANGES FOR CANS AND PSC-35
The administration of the CANS and PSC-35 depends
on the age of the beneficiary, not the program inwhich the beneficiary is enrolled. Depending on theage of the client, both a PSC-35 and a CANS may bothbe required.
CANS

PSC-35

3-18 years

6-20 years

Page 45 of 114

Timelines for CANS and PSC-35
BHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity

BHRS Clinical Staff: All BHRS clinical staff are required to administer the CANs for the beneficiaries and time frames specified in
the memo. Staff must be CANS-certified before administering the CANS and must maintain annual certification status. BHRS
Quality Management will track that BHRS clinical staff are CANS-certified. To become CANS-certified, first create an account with
the PRAED Foundation: https://www.schoox.com/academy/CANSAcademy/register and then contact
HS_BHRS_QM@smcgov.org to access the CANS training code. You must provide the certificate of completion of the CANS
training to QM immediately after completing/passing the online exam. The programs responsible for completing the assessment
are also responsible for completing the CANS and PSC-35. BHRS clinical staff will complete the CANS directly in Avatar. A paper
version may be utilized but the information must also be entered into Avatar. CANS can be found in Avatar as the form titled:“Child and Adolescent Needs and Strengths.”
Contractor Staff: All contractors are required to be CANS-certified before administering the CANS, and to maintain annual
certification status. Contract agencies are required to track certification of their staff and this must be made available uponrequest. The PRAED foundation is the only certifying body: https://praedfoundation.org/training-and-certification.

Additional Assessment Tools

Contractors with Avatar administrative access will utilize the paper version of the forms and will either have theiradministrative staff enter the information into Avatar or submit the documentation to the BHRS MIS department to be entered,depending on their agency’s workflow. Paper versions will be kept in their agency’s official medical record. Contractor ClinicalStaff will complete the CANS in their official medical record and submit the CANS data set to their administrative staff for entry
into Avatar, or it may be sent to BHRS MIS for entry into Avatar.

Diagnosis

TIMEFRAME: THE CANS AND PSC-35 SHOULD BE COMPLETED AT THE FOLLOWING POINTS IN TIME:

Screening Tools
Assessment

Problem List
Care Planning
Coordination of Care
Discharges and Transfers
Coding Services

At
Admission*

Every 6
MonthsAt
Discharge

Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions

And whenever there is a clinically significant change.
*Must be completed within approximately 60 days of admission.

C – Progress Note Templates
Last Updated: 10/17/2024

Page 46 of 114

BHRS SMHS Eligibility Tool
BHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance

The determination of whether a beneficiary meets or continues to meet Access Criteria for SMHS, including whether or nottransition of care should occur and the determination of what services are medically necessary, must be made by a clinician.
DHCS allows for the development of protocols, which could include the use of a rubric or other methodology, to support thisdetermination. The use of the BHRS SMHS Eligibility tool does not replace a full clinical assessment. It is intended to be used tosupport staff’s ability to confirm their determination of eligibility after the completion of the full assessment (or reassessment).
BHRS currently has three versions of the BHRS SMHS Eligibility Tool to support clinical staff in determining if a beneficiary meets
criteria to access specialty mental health services.

Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools
Diagnosis

When and How should this Tool be used?
Use of the BHRS SMHS Eligibility Tool is optional.

Problem List
Care Planning
Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

The SMHS Eligibility Tool is intended to be used as a supervisory tool
to help supervisors in supporting their staff’s learning of how todetermine if an individual meets criteria to access SMHS. It is notmeant to replace clinical decision making, nor is it meant todetermine the specific types of services that are medically necessary.
The BHRS SMHS Eligibility Tool may be used whenever there is adetermination being made about whether or not a beneficiary meetsor continues to meet Criteria to Access SMHS. This includes: the Initial
Assessment, Reassessment(s), and at Discharge.

DOCUMENTATION REMINDERThe use of the BHRS SMHS Eligibility tool does not
replace a full clinical assessment. It is intended to
be used to support staff’s ability to validate theirdetermination of eligibility after the completionof the full assessment (or reassessment).

Please refer to the Assessment section of this manual for more guidance on when a reassessment should be conducted.

What staff /programs may use the BHRS SMHS Eligibility Tool?
Only LPHAs for whom it is within their scope of practice to finalize assessments may use the BHRS SMHS Eligibility Tool. Pleaserefer to the Scope of Practice Matrix on the BHRS QM website for information on who may finalize assessments.
Page 47 of 114

Structure of the BHRS SMHS Eligibility Tool
BHRS Documentation
Manual for SMHS
Table of Contents

The BHRS SMHS Eligibility Tools align with the Criteria for Access to SMHS based on age group, and an additional set of criteria isprovided to help staff assess whether or not an individual’s level of functioning would be considered, for instance, a “significant
impairment” or a “probability of significant deterioration.”

YOUTH (0-5 YEARS AND 6-20 YEARS)The Youth (0-5) and Youth (6-20) Eligibility Tool include 3 checklists.

Introduction
Compliance

Checklist 1

Documentation Requirements• Criteria 1

Access to SMHS and Medical
Necessity
Screening Tools
Assessment

Checklist 2

Checklist 3• Criteria 2• Criteria 2A

Checklists 1 and 2

Additional Assessment Tools

The first two checklists are checklists that directly align with Criteria 1 and Criteria 2 of the Criteria to Access to SMHS criteria forbeneficiaries under 21 years of age (See “Access to SMHS” section of this manual for details on these criteria).

Diagnosis

Checklist 3

Problem List

The third checklist, titled Criteria 2A, is to support staff’s determination of whether or not the beneficiary may likely meet
Criteria 2A. Criteria 2A includes that the youth beneficiary must have at least one of the following:

Care Planning•a significant impairment;

Coordination of Care•a reasonable probability of significant deterioration in an important area of life functioning;

Discharges and Transfers•a reasonable probability of not progressing developmentally as appropriate;

Coding Services•

and/or a need for SMHS, regardless of presence of impairment, that are not included within the mental health benefits
that a Medi-Cal managed care plan is required to provide.

Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix

Criteria 2A is a checklist that supports staff’s ability to determine if, for example, the beneficiary’s functioning indicates a“significant impairment” that would satisfy the requirements for A under Criteria 2A.
Beneficiaries 20 years and under only need to meet criteria in either Criteria 1 or Criteria 2, not both. However, in order for abeneficiary to be eligible to access SMHS under Criteria 2, both Criteria 2A and Criteria 2B must be met.

B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

Page 48 of 114

ADULTS (21+ YEARS)BHRS Documentation
Manual for SMHS

The Adult (21+ years) Eligibility Tool also includes 3 checklists.

Checklist 1• Criteria 1

Table of Contents

Checklist 2• Criteria 2

Checklist 3• Criteria 1A

Introduction
Compliance

Checklists 1 and 2

Documentation Requirements

The first two checklists are checklists that directly align with Criteria 1 and Criteria 2 of the Criteria to Access to SMHS criteria forbeneficiaries 21 years of age and older (See “Access to SMHS” section of this manual for details on these criteria).

Access to SMHS and Medical
Necessity

Checklist 3

Screening Tools

The third checklist, titled Criteria 1A, supports staff’s determination of whether or not the beneficiary may likely meet Criteria 1.

Assessment

Criteria 1 requires that an adult beneficiary has either:

Additional Assessment Tools
Diagnosis
Problem List
Care Planning
Coordination of Care
Discharges and Transfers•a significant impairment, where impairment is defined as distress, disability, or dysfunction in social,•a reasonable probability of significant deterioration in an important area of life functioning.

occupational, or other important activities, AND/OR

Criteria 1A is a checklist that supports staff’s ability to determine if, for example, the beneficiary’s functioning
indicates a “significant impairment” that would satisfy the requirement to meet Criteria 1.
Beneficiaries 21 years of age and older must meet both Criteria 1 and Criteria 2 to be eligible to access SMHS.

Coding Services

What if my clinical determination is different from the result of the BHRS SMHS Eligibility Tool?

Progress Notes

If staff’s determination regarding the beneficiary’s eligibility at the conclusion of the assessment is different from the outcomeof the BHRS SMHS Eligibility tool, staff should consult with their supervisor to review the draft of the full assessment and thecompleted tool to explore reasons for the discrepancy. Staff and supervisors should use their clinical expertise to make theappropriate determination of eligibility.

AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

In addition to making a clinical assessment of the beneficiary’s medical necessity, best practice is to include beneficiaries inongoing conversations throughout treatment including reviewing treatment progress, potential transitions or changes in typesof services offered, and readiness for transition. If transitioning a beneficiary to another level of care, the transition should
happen within a clinically appropriate timeframe as determined by the clinician in collaboration with the beneficiary.
Page 49 of 114

DIAGNOSISBHRS Documentation
Manual for SMHS

Compliance

Information used to determine a diagnosis is obtained through aclinical assessment and may include a series of structured tools.
Information may come directly from the person in care or throughother means, such as collateral information or health records. A
diagnosis captures clinical information about the person’s mental
health needs and other conditions based on the DSM-5. Diagnoses
are determined by an LPHA commensurate within their scope ofpractice (See Scope of Practice Matrix).

Documentation Requirements

Diagnoses serve several purposes, including, but not limited to:Table of Contents
Introduction

Access to SMHS and Medical
Necessity



Screening Tools
Assessment
Additional Assessment Tools
Diagnosis
Problem List
Care Planning
Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

Diagnoses are used to communicate with other teammembers about the person’s mental health symptoms andother conditions and may document the level of
distress/impairment.
Diagnoses also help guide practitioners in their advisement
about treatment options to the person in care.

Diagnoses should not remain static. For example, the person’s
clinical presentation may change over time and/or the practitioner
may receive additional information about the person’s symptoms
and how the person experiences their symptoms(s) and conditions.
As a practitioner, it is solely the responsibility of the LPHA acting
within their scope of practice to ensure that all mental healthdiagnoses in the problem list are up-to-date. This includes
documenting all diagnoses, including preliminary diagnostic
impressions and differential diagnoses. The LPHA should also
update the health record of the person in care whenever adiagnostic change occurs.

WHAT IS MEANT BY THE TERM
“DIAGNOSIS”?
To provide further clarification regarding diagnoses
that can be added to the problem list, thisdocumentation manual will use the following
definitions:
Mental Health Disorders – refers to diagnoses (using“F” and certain “Z” codes in the ICD-10) that MUST
be diagnosed by an LPHA. These diagnoses may be
used for the purpose of determining whether abeneficiary meets criteria for access to the SMHS
delivery system.
Mental Health Disorders include, for instance, Major
Depressive Disorder or Post-Traumatic Stress
Disorder, but does NOT include substance-related
and addictive disorders (e.g., stimulant use disorder)or neurocognitive disorder (e.g., dementia).
Social Determinants of Health – refers to a subset of
Z-Codes that represent various social factors and life
circumstances that may impact a beneficiary’sfunctioning. These may be identified by an LPHA or
non-LPHA and are not considered “mental healthdisorder” diagnoses.

While there is no longer a limited set of diagnosis codes that are allowable in relation to the provision of SMHS, the covered
benefits and services responsibilities of the MHPs and MCPs remain unchanged. For example, MHPs are not required to provide
Applied Behavior Analysis (ABA), a key intervention in the treatment of autism spectrum disorder (ASD), as the responsibility forproviding that service remains with the MCP. However, a person in care who has ASD is able to additionally receive treatment
from the MHP if their service needs require it and services are not duplicative with the other care they are receiving.
Page 50 of 114

Diagnosis Scope of Practice
BHRS Documentation
Manual for SMHS

The introduction of the “Problem List” under CalAIM allows for both LPHAs and non-LPHAs to add items to the Problem List.
However, LPHAs and non-LPHAs differ in the types of “problems” they can add to the Problem list. While LPHAs diagnose mental
health conditions such as Major Depressive Disorder, non-LPHAs are limited to adding only a subset of the Z-codes in the ICD-10,
commonly referred to as social determinants of health.

Table of Contents

For purposes of clarity, the term “diagnosis” in this manual will be used for those codes that may only be diagnosed by an LPHA.
Z-Codes that may be used by all providers, including non-LPHAs, will be referred to as “Z-Codes” or “Social Determinants ofHealth (SDOH)” and will NOT be referred to as Diagnoses.

Introduction
ComplianceDiagnosis codes for use by LPHAs

Documentation Requirements
Access to SMHS and Medical
Necessity•

Any clinically appropriate code.

•

Z03.89 (Encounter for observation forother suspected diseases andconditions ruled out).

Screening Tools
Assessment•

Additional Assessment Tools
Diagnosis“Other specified” and “Unspecified”
disorders,” or “Factors influencing
health status and contact with healthservices.”

Z-Codes for Use by All Providers*•

Z55-Z65 (Persons with potential healthhazards related to socioeconomic andpsychosocial circumstances).

*May be used during the assessment periodprior to diagnosis; do not require supervision ofa Licensed Practitioner of the Healing Arts
(LPHA).

Problem List
Care Planning
Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
Last Updated: 10/17/2024

Diagnoses Oversight
Formulation of a diagnosis requires a provider, working within their scope of practice, to be licensed, waivered and/or under
the direction of a licensed provider in accordance with California State law. Determining a diagnosis is within the scope ofpractice for the following provider types: Physician, Psychologist, Licensed Clinical Social Worker, Licensed Professional ClinicalCounselor, Licensed Marriage and Family Therapist, and Advanced Practice Nurses (in accordance with the Board of Registered
Nursing.)
LPHAs are responsible for reviewing the diagnoses entered into a beneficiary’s problem list, including Z-codes entered by nonLPHAs.
All diagnoses, including any substance use diagnosis, must be included on the mental health Assessment.** Note that this does NOT include diagnoses or other information that falls under 42 CFR Part 2 privacy restrictions.

Page 51 of 114

Diagnosis and Billing
BHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools

Clarification Regarding “Claimable” Diagnosis Codes
Services provided prior to determination of a diagnosis (including services provided during the assessment, or prior todetermination of SMHS access criteria) are covered and reimbursable even if the assessment ultimately indicates the beneficiary
does not meet criteria for access to SMHS.
However, while a mental health diagnosis is not a prerequisite for access to covered services and while a person may accessnecessary services prior to determining a diagnosis, an ICD-10 code must be assigned to submit a service claim forreimbursement.
In cases where services are provided due to a suspected disorder that has not yet been diagnosed, options are available for an
LPHA in the CMS approved ICD-10 diagnosis code list, which may include Z codes. LPHAs may use any clinically appropriate ICD10 code. For example, these include codes for “Other specified” and “Unspecified” disorders,” or “Factors influencing healthstatus and contact with health services.”

SELECTING A “PRIMARY” DIAGNOSIS

Diagnosis

An ICD-10 Code that is the focus of treatment should be identified as the “Primary” diagnosis as this is the code that will be
attached when claiming (billing) services.

Problem List•

Care Planning
Coordination of Care
Discharges and Transfers•

When a more definitive mental health diagnosis (not a Z-code) isdetermined for the client, the diagnosis should be updated in the chart assoon as the diagnosis is determined. If more than one mental healthdiagnosis is appropriate for the client, select the one that is the primary
focus of treatment as the “Primary” diagnosis.

•

You may provide treatment for the other diagnoses that are added even if
they are not the primary diagnosis as long as treatment of the condition iswithin your scope of practice and any applicable care planningrequirements are met.

Coding Services
Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions

During the Assessment phase, if a formal mental health diagnosis is not
yet determined, clinicians should use code Z03.89 (Encounter for
observation for other suspected diseases and conditions ruled out) as theprimary diagnosis.

ARE Z-CODES ACCEPTIBLE“ICD-10” CODES FOR
CLAIMING PURPOSES?
Z-codes meet the federal requirement
for claims which is why they may be
the primary code used during theassessment phase. Keep in mind,
though, Z-codes do not indicate adiagnosis of a mental health disorder
or a substance use disorder.

C – Progress Note Templates
Last Updated: 10/17/2024

Page 52 of 114

MORE ABOUT Z-CODESBHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools

A Z-code alone may be utilized while a clinician takes time to gather information about
the beneficiary's presenting needs and determine the most appropriate diagnosis andnext steps. However, the Z-code should not be utilized indefinitely (see access to SMHS
criteria for beneficiaries 21 and up) as it may be challenging to justify ongoing medical
necessity for SMHS without a formal diagnosis of a “mental health disorder” (e.g., an“F-Code” diagnosis, such as Depressive Disorder or Schizophrenia).
In some settings or for some service types, particularly with children and youth,
services can more easily be justified based only on Z codes. In these cases, consult withyour supervisor and QM to determine if you have a case which should continue using
only a Z code.

DOCUMENTATIONREMINDER
The assessment or otherdocumentation in the medical
record should substantiate theuse of a Z-code.

ADDITIONAL GUIDELINES FOR “BY HISTORY,” “RULE OUT,” AND “PROVISIONAL” DIAGNOSES“By history,” “Rule Out,” and “Provisional” diagnoses may be included as part of the list of diagnoses, but they should not be thesole diagnoses on record for the beneficiary if the beneficiary is receiving ongoing SMHS post-assessment. The beneficiary
should meet criteria for a mental health diagnosis at the completion of the assessment to meet medical necessity criteria for
ongoing SMHS. If there is no clear clinical diagnostic picture at the conclusion of the assessment, reconsider if the assessment
was completed prematurely prior to the acquisition of the necessary information to determine a diagnosis, or if the beneficiary
should be seen in a lower level of care (a.k.a., mild-to-moderate services through the MCP).

Diagnosis

Other Diagnosis‐Related Issues

Problem List
Care Planning
Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes
Appendices

DIAGNOSES FROM INPATIENT FACILITIESAn assessment, which includes a diagnosis, evaluates the current status of a beneficiary’s mental, emotional or behavioral
health. This status may change as a beneficiary transitions from inpatient to outpatient services. Therefore, providers should not
rely on an inpatient diagnosis when conducting an assessment for outpatient services. However, the inpatient assessment
documents should be reviewed to inform the outpatient assessment process and to verify that the diagnosis reflects thebeneficiary’s current mental, emotional or behavioral health status.

MULTIPLE PROVIDERS AND MULTIPLE DIAGNOSESA – Service Code, Location
Code, Time Field Matrix•

If there is a difference of opinion between providers regarding a beneficiary’s diagnosis—e.g., between a physician and atherapist—it is best practice for the providers involved to consult and collaborate to determine the most accurate diagnosis.

B – Service Definitions•

A beneficiary’s diagnosis may be used by multiple providers if the diagnosis reflects the current status of the beneficiary’s
mental, emotional, or behavioral health.

C – Progress Note Templates
Last Updated: 10/17/2024

Page 53 of 114

CHANGE OF DIAGNOSISBHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements•

A Reassessment and change in diagnosis may be required when a beneficiary has experienced a significant medical or clinicalchange.

•Assignment of a mental health diagnosis may be deferred until the completion of the assessment. A diagnosis listed asprovisional or rule‐out should be confirmed or changed upon the completion of the assessment and determination of
medical necessity. Diagnoses may be changed at any time during the course of treatment.

DIAGNOSIS & TREATMENT WITHOUT MEETING ACCESS CRITERIA FOR SMHS
Occasionally, it may be appropriate to provide ongoing treatment services to a beneficiary whose condition does not meet
Criteria for Access to SMHS. In these cases, the clinician must obtain supervisor approval to continue treating the beneficiary
after the assessment period.

Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools
Diagnosis
Problem List
Care Planning
Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

Page 54 of 114

PROBLEM LISTBHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools
Diagnosis
Problem List
Care Planning
Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

Page 55 of 114

CARE PLANSBHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements

Pre-CalAIM Care Plans (Treatment Plans)
Until BHRS implements the new CalAIM Care Plan requirements, staff should continue to follow guidelines for pre-CalAIM
Treatment Plan requirements using the existing “Client Treatment and Recovery Plan” form in Avatar or the PDF version of theform. Below are the Pre-CalAIM Treatment Plan Guidelines. This Pre-CalAIM section will be removed and replaced with a new
Care Plan section that includes new CalAIM guidelines in November 2024 to coincide with the Care Planning Training that will
be offered that month.

Access to SMHS and Medical
Necessity

Client Treatment and Recovery Plan (Formal Plan)

Screening Tools

The Client Treatment & Recovery Plan is a primary way of involving clients in their own care. The development of the Client Plan
is a collaborative process between the client and their treatment team.

Assessment
Additional Assessment Tools
Diagnosis
Problem List
Care Planning
Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

It is designed to establish the client’s treatment goals, develop a set of objectives to help realize these goals, and reachagreement on the services we will provide. Program goals should be consistent with the client’s/family’s goals as well as thediagnosis and assessment. The client plan must include documentation of the client’s participation in the development of andagreement with the client plan.

CLIENT PARTICIPATION
Client participation in the formulation of the treatment plan is documented by obtaining the signature or verbal approval of theclient/parent/guardian and when possible providing a copy of the plan to the client/family member, and, most importantly,
documenting in a Plan Development or medication support progress note how the client/parent/guardian participated indeveloping and approving the treatment plan.
It is not sufficient to write on the plan or in a progress note that the client missed the Plan Development appointment or could
not be reached; this does not describe the client’s participation.
It must be documented if a copy of the plan was offered to the client and if the client accepted or declined the copy. Offering a
copy of the plan to the client/family member is an important acknowledgment of the client’s involvement in the development of
the client plan, and demonstrates the clinician’s commitment to involving clients/families as full participants in their own
recovery process.
Treatment Plans should be written in the client’s preferred language., if possible. If the preferred language is not English, thetreatment plan must be translated into English as well.
Page 56 of 114

THE 9 ELEMENTS REQUIRED BY THE CURRENT CLIENT PLAN

BHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools
Diagnosis
Problem List
Care Planning
Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

1. Statement of the problem to be addressed;
2. An expected frequency for each proposed intervention;
3. An expected duration for each proposed intervention and dates;
4. Specific behavioral interventions (description) for each proposed service and how it will ameliorate diagnosis;
5. Observable and measurable goals and objectives; SMART (*See p. 15)
6. Provider’s signature with Degree/License or job title, and signature date, and co-signature of LPHA if applicable;
7. Adequate documentation that the beneficiary was offered a copy of the Plan;
8. Client’s dated signature (or progress note documenting verbal approval);
9. Documentation that the beneficiary participated in development of and agreed to the Plan

Treatment Plan Timelines
A client plan must be completed prior to service delivery of all Planned Services*. The State Plan requires services to be provided
based on medical necessity criteria, in accordance with an individualized client plan and an approved and authorized
assessment, according to State of California requirements. The client plan must be updated at least annually or when there are
significant changes in the client’s condition.
For all programs the treatment plan must be completed within 60 days from admission to your program. A new treatment planshould be completed before the previous plan expires; there should be no gap between treatment plans.
A client plan is required whether a client receives only one service modality or multiple service modalities. Specialty Mental
Health Services are to be provided based on medical necessity criteria, in accordance with an individualized client plan.
The Client Plan may be authorized for a maximum of one year. The client plan shall be renewed— reviewed and modified—every 365 days from the start date of the previous client plan.

REVIEWING THE PLAN WITH THE CLIENT
If the client is not available to participate in the review prior to the expiration of the 365-day period, the annual Client Plan shallbe reviewed and updated with the client at the next contact prior to providing any additional treatment services. The review
shall be documented in a Plan Development progress note, including outcomes, progress (or lack thereof) on the previous
treatment plan’s goals/objectives. The note should include the client’s participation in formulating the plan, and approval of theplan (can be verbal approval).

Page 57 of 114

Updates to Treatment PlanBHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance

The Client Treatment & Recovery Plan must be updated at least annually or when there is a significant change in the client’s
condition—e.g., major life change such as divorce, loss of job, death in family, change in living situation...etc.
There is no specific language in regulation that defines a “significant change” in a client’s condition, but some factors that would
warrant an updated Client Plan include:
A client’s symptoms or behaviors change radically—e.g., a client who has never been suicidal makes a suicide attempt, there is asudden increase in severity of symptoms, or a client who has been attending therapy regularly suddenly stops coming toappointments...etc.

Documentation Requirements

Treatment Plan Signatures

Access to SMHS and Medical
Necessity

The client’s verbal approval and/or signature or the verbal approval and/or signature of the client’s parent required on theclient plan when the client is expected to be in long-term treatment and when the plan indicates that the client will be receiving
more than one Specialty Mental Health Service. Verbal approval, with a progress note documenting agreement, from client orclient’s caregiver is acceptable. The definition of “Long-Term Treatment” is a client that is seen for more than one treatment
session. And a “Long-Term Client” is any client admitted to an outpatient treatment episode.

Screening Tools
Assessment
Additional Assessment Tools
Diagnosis
Problem List
Care Planning
Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

REFUSAL TO SIGN OR UNAVAILABILITY TO SIGN
If the client/parent refuses to sign or is unavailable to sign the treatment plan, a detailed progress note must be written to
explain the client’s participation in developing the plan and/or agreement to treatment in general, and the reason for the
missing signature. Verbal approval, with a detailed progress note, is also sufficient if you cannot meet with client or caregivers inperson. It is expected that you would follow best practice protocols and make additional attempts to obtain the client’s verbal
approval and/or signature and document these attempts in the client’s chart. We do not recommend writing “clinician willobtain signature during next session.”

MINORS CAN SIGN (OR GIVE VERBAL APPROVAL) TO THEIR OWN CLIENT PLANS
There is no minimum age for a minor to independently sign a treatment plan. The plan is a collaborative process between theclient and the provider. The minor client should understand that what they are signing is based on their participation in theprocess.
In order to update a plan without a client signature, the clinician must document the client’s involvement in plandevelopment—e.g., a telephone discussion about the plan—and document this involvement (and approval of the plan) by theclient on the treatment plan AND in a Plan Development progress note. It is not sufficient to document this client involvement
only on the plan itself; a Plan Development or medication support note must be written whenever you work with a client toformulate/review/obtain approval for a treatment plan.
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Staff Who Must sign the Client PlanBHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools

A client plan must be signed (or electronic equivalent) with a credential, and dated by either the person providing the services, aperson representing a team or program providing the services, or a person representing BHRS who is providing the services. In
addition to a signature by one of the forgoing staff, the plan must be co-signed by one of the following providers if the client
plan indicates that some services will be provided by a staff member under the direction of one of the categories of staff listed
below, and/or the person signing the client plan is not one of the categories of staff listed below:
 Physician
 Licensed/waivered Psychologist
 Licensed/registered/waivered Clinical Social Worker
 Licensed/registered/waivered Marriage & Family

Therapist Licensed/registered/waivered Professional Clinical Counselor
 Registered Nurse, Nurse Practitioner (NP), Clinical Nurse Specialist
A client plan is effective once it has been signed with a credential (and co-signed, if required) and dated by the required staff
member(s). Drafts are not considered to be complete.

Diagnosis

Services that Require a Treatment Plan

Problem List

An approved Client Plan MUST be in place before the following services may be provided:

Care PlanningMental Health services (except assessment, client plan development, crisis intervention, urgent Med Support)

Coordination of Care

Intensive Home-Based Services (IHBS)

Discharges and Transfers



Coding Services

Specific component of TCM and ICC: Monitoring and follow-up activities to ensure that the client plan is being
implemented and that it adequately addresses the client’s individual needs

Progress Notes



Therapeutic Behavioral Services (TBS)Appendices

Day Treatment Intensive

Day Rehabilitation



Adult Residential treatment services

B – Service Definitions

Crisis Residential treatment services

C – Progress Note Templates

Medication Support (non-emergency)

A – Service Code, Location
Code, Time Field Matrix

Last Updated: 10/17/2024

Page 59 of 114

BHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools



Psychiatric Health Facility services



Psychiatric Inpatient services

For any TCM, ICC, and Medication Support Services provided prior to a client plan being in place, the progress notes must clearlyreflect that the service activity provided was a component of a service that is reimbursable prior to an approved client plan
being in place, and not a component of a service that cannot be provided prior to an approved client plan being in place.

Treatment Plan Elements
CLIENT’S OVERALL GOAL/DESIRED OUTCOME
The client’s desired outcome from successful treatment.
This is the reason the client is seeking treatment. Overall goals are broad life goals, such as returning to work or graduating fromhigh school, that reflect the client’s intent and interests. The overall goal should be clear to the client and the treatment team,and it should reflect the client’s preferences and strengths. These goals have a special place in a system committed to recovery –they should speak to the client’s ability to manage or recover from his/her illness and to achieve major developmental
milestones.

DIAGNOSIS/RECOVERY BARRIER/PROBLEM

Diagnosis

Primary Diagnosis’ signs/symptoms/impairments, and other barriers/challenges/problems. Describes the behavioral healthsymptoms and impairments that are the focus of treatment.

Problem List

GOAL

Care Planning

The removal or reduction of the problem.

Coordination of Care

The goal addresses the problem. The goal is the development of new skills/behaviors and the reduction, stabilization or removalof the barrier/problem. Individual goals address the barriers that prevent clients from reaching overall goals. They are generally
related to important areas of functioning that are affected by the client’s mental health condition such as daily activities, school,
work, social support, legal issues, safety, physical health, substance abuse and psychiatric symptoms. The treatment plan mustclearly document how a goal is connected to the client’s mental health condition. Goals must relate to the diagnosis and caseformulation.

Discharges and Transfers
Coding Services
Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

OBJECTIVE(S)What the client will do to reach the goal.
This is a breakdown of the goal. It may include specific skills the client will master and/or steps or tasks the client will complete
to accomplish the goal. Objectives should be specific, observable, quantifiable, and related to the assessment and diagnosis. A
simple mnemonic that may be helpful when working with the client to develop program objectives is S.M.A.R.T. (Specific,
Measurable, Attainable, Relevant, Time-bound).
Page 60 of 114

INTERVENTION(S)

BHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools
Diagnosis
Problem List

The specific services that staff will provide.
These are all of the service types that will be utilized in treatment (e.g., Medication Support, Case Management, Individual
Therapy, Group Therapy, etc. ) List all that apply.
A proposed intervention is the service that the provider anticipates delivering to the client when formulating the client plan withthe client. It is the proposed type of intervention/modality—e.g., “DBT-based individual therapy to reduce client’s selfharming/cutting behaviors.” There may be several of these on the plan, depending on the scope of services to be provided.
The actual intervention is the specific intervention utilized during the mental health service; each actual intervention is
documented, along with the client’s response, in a progress note.
Interventions describe specific, diagnosis-driven actions to be taken by BHRS providers —for each service type— to assist clientsin achieving their program goals. Do not merely list “Mental Health Services” or “Targeted Case Management” as theplanned/proposed intervention.

DURATION OF INTERVENTION
Usually this will be 12 months, but it may be 3, 6, or 9 months, if appropriate. This time frame is a prediction of how long theintervention will be needed; it is the total expected timespan of the service. (E.g., “Client will attend two individual therapy
sessions per week for 6 months.”)
A Client Plan in which all interventions have a duration of less than one year must be updated on time (before they expire), prior
to the annual due date.

Care Planning

FREQUENCY OF INTERVENTION

Coordination of CareUse of terms such as “as needed” or “ad hoc” do not meet the requirement that a client plan contain a proposed frequency forinterventions. The proposed frequency must be stated specifically (e.g., daily, weekly, etc.) or as a frequency range (e.g., 1-4 x
per month).

Discharges and Transfers
Coding Services
Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

Page 61 of 114

Examples of Treatment Plan Elements
BHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools
Diagnosis

Examples of Recovery Barrier/Problems linked to Diagnosis
 Auditory hallucinations leading to self-harm and hospitalization.
 Exhibits angry behavior in class; refuses to complete tasks or accept help; learning disabilities impede progress in school.
Examples of Goals
 Reduce auditory hallucinations and improve symptom management.
 Get along better with others at school, without physical aggression.
Examples of Objectives
 From a baseline of 0, I will meet with MD 1x/month to discus positive and negative impact of medication over the next
12 months.
 Within 12 months, I will identify at least 2 activities, from a baseline of 0 activities, that will help me not listen tonegative voices.
 Within 12 months, I will have at least one friendly talk with peers 2-3 times per week from a baseline of 0 friendly talks
weekly.
Examples of Interventions

Problem List

 Provide monthly medication support services to assess and monitor medication compliance, client’s response and side
effects.

Care Planning Provide rehab services weekly to assist client in performing ADLs and reducing anxiety.

Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

 Provide targeted case management every 3 months to coordinate with VRS so client can reduce depression and achieve
employment goals.
Examples of specific, diagnosis-related interventions
 Clinician will provide Individual Therapy 1x per week, for 6 months, utilizing Cognitive-Behavioral techniques, to assist
client to reduce his anxiety.
 (AOD) Case Management to be provided twice monthly, for 1 year, to ensure that client is utilizing support/resources tomaintain sobriety.
 Medication Management 1x per month to monitor/stabilize client’s psychotic Sx.
 Every proposed intervention for each service type—such as Individual Therapy, Medication Support and/or Targeted
Case Management—must be listed and described in detail. Any intervention added during the course of treatment (e.g.,TBS) must be written and dated on the plan. If a proposed intervention is not included on the treatment plan, that
service cannot be provided and billed for.
Page 62 of 114

CalAIM Care Plans
BHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools
Diagnosis
Problem List
Care Planning
Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

Page 63 of 114

COORDINATION OF CAREBHRS Documentation
Manual for SMHS

All Staff are responsible for ensuring that they are up-to-date on regulations and policies related to sharing of information,
including sharing of information as it relates to coordination of care.

Table of Contents
Introduction
Compliance
Documentation Requirements

RELATED POLICIES TO REVIEWThe policies below are the main policies related to care coordination and sharing PHI and medical records
with other providers.
Please note that there are additional policies not listed below that may be related to a particular
population, program, or situation.

Access to SMHS and Medical
Necessity

Policy 23-01: Adult and Youth Screening and Transition of Care Tools

Screening Tools

Policy 22-03: No Wrong Door for Mental Health Services

Assessment

Policy 93-13: Restricted Material in Beneficiary Chart

Additional Assessment Tools

Policy 96-15: Application for Services and Consent to Treatment

Diagnosis

Policy 03-01: Confidentiality - Privacy of Protected Health Info (PHI)

Problem List

Policy 03-02: Notice of Privacy Practices

Care Planning

Policy 03-04: Disclosure of Protected Health Information (PHI) Minimum Necessary

Coordination of Care

Policy 03-05: Disclosures of Protected Health Information (PHI), Incidental

Discharges and Transfers

Policy 03-06: Disclosures of Protected Health Information (PHI) with Beneficiary Authorization

Coding Services

Policy 03-08: Restrictions on Use or Disclosure of Protected Health Information (PHI), Beneficiary Request

Progress Notes

Policy 03-09: Amendment of Protected Health Information (PHI), Beneficiary Request

AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

Page 64 of 114

Co-Occurring Substance Use Disorders
BHRS Documentation
Manual for SMHS

Beneficiaries may present in any behavioral health setting with any combination of mental health and substance use symptoms
or disorders. Mental health disorders may or may not be substance‐induced, and the mental health and substance use
conditions may be active or in remission.

Table of Contents

SCREENING FOR SUD

Introduction

For information on how beneficiaries get screened then referred
for SUD services, see the Screening Tools Section.

Compliance
Documentation Requirements

DIAGNOSIS

CO-OCCURRING VS CO-MORBID
San Mateo County Behavioral Health and Recovery
Services (BHRS) assesses and treats co‐occurring
disorders including substance abuse/dependency,
trauma‐ related disorders, and developmental
disorders.

Assessment

All diagnoses for mental illness and substance abuse/dependence
shall be documented in the BHRS chart when criteria are met.
However, keep in mind that substance-related and addictive
disorders (e.g., stimulant use disorder) are not “mental healthdisorders" for the purpose of determining whether a member
meets criteria for access to the SMHS delivery system.

Additional Assessment Tools

CARE PLANNING OF SERVICES

Diagnosis

Discharges and Transfers

Care Planning for beneficiaries and families with children with co‐occurring disorders must address both mental health andsubstance use issues. Care Planning (including the problem list
and, if required, formal treatment plans) will be tailored to thebeneficiary’s readiness to address an issue, with the understandingthat the beneficiary and family members may have different levelsof readiness to address each issue.

Coding Services

PROGRESS NOTESProgress Notes

Mental health progress notes will document ongoing assessment and monitoring of co‐occurring substance use issues. These
notes will focus on how substance use may be exacerbating mental health issues or impeding recovery from a mental illness,and how integrated interventions will promote mental health recovery.

Access to SMHS and Medical
Necessity
Screening Tools

Problem List
Care Planning
Coordination of Care

AppendicesA – Service Code, Location
Code, Time Field Matrix

Because this section focuses on Substance Use
Disorders, the following definitions will be used forthis section:
Co-Occurring Disorders: The coexistence of both a
Mental Health diagnosis and Substance Use
Disorder.
Co-Morbid: Moves beyond the existence of cooccurring diagnoses. When a beneficiary is
experiencing a co-morbidity, it means, that theinteractions between these co-occurring disorders
can worsen the course of both.

B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

Page 65 of 114

Integrated System
BHRS Documentation
Manual for SMHS

For beneficiaries and families with co‐occurring conditions and other complex needs, the provision of integrated services
matched to the multiple needs of the beneficiary and/or family is an evidence‐based practice. The “No Wrong Door” Policy
under CalAIM makes it easier for beneficiaries with these co-occurring diagnoses to be seen concurrently by the MH and SUD
systems. The following guidelines should be used when treating individuals with co-occurring diagnoses.

Table of Contents

BENEFICIARIES IN A MH PROGRAM WHO ALSO HAVE AN SUD DIAGNOSISIntroduction

 Clinically appropriate and covered SMHS delivered by BHRS Mental HealthCompliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools

Providers are covered Medi-Cal services whether or not the beneficiary has aco-occurring SUD.

 The session must primarily address the member’s mental health, e.g. symptom,
condition, diagnosis, and/or risk factors which can include co-occurring SUD.

 The reason for the service encounter must include an ICD-10-CM code that
corresponds to their mental health.

Assessment

BENEFICIARIES IN AN SUD PROGRAM WHO ALSO HAVE MH DIAGNOSIS

Additional Assessment Tools

 Clinically appropriate and covered DMC-ODS services delivered by DMC-ODS

Diagnosis
Problem List
Care Planning
Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

WHAT ARE DMC-ODS
PROGRAMS?
Put simply, Drug Medi-Cal Organized
Delivery System (DMC-ODS) is
another term for health plans thatprovide Substance Use DisorderServices under Medi-Cal. BHRS’ SUD
delivery system falls under the DMCODS category.

providers are covered by DMC-ODS counties, whether or not the beneficiary has a co-occurring mental health condition.

 The session must primarily address the member’s substance use, e.g. symptom, condition, diagnosis, and/or risk factors,
which can include co-occurring mental health conditions.

 The reason for the service encounter must include an ICD-10-CM code that corresponds to their SUD.
CO‐OCCURRING DISORDER
Youths, adults and older adults are considered to have a co‐occurring disorder when they exhibit the co‐occurrence of mental
health and substance use/abuse problems, whether or not they have already been diagnosed. Co-occurring disorders vary
according to severity, duration, recurrence, and degree of impairment in functioning. The significant co‐morbidity rates of SUDs
and mental illness are typically reported as 40 percent to 80 percent, depending on study characteristics and population. Thereis a growing body of research associating poorer outcomes with a lack of targeted treatment efforts. These studies havehighlighted the importance of addressing the unique needs of this population.

CO‐OCCURRING FAMILIESFamilies in which a significant family member /caregiver of a beneficiary has a substance use issue. Integrated services anddocumentation apply to co‐occurring families as well as to co-occurring beneficiaries receiving adult or child mental healthservices funding. However, clinicians must use care when documenting family member /caregiver SUD in the beneficiary’s chart.
Page 66 of 114

Beneficiaries Shared Between BHRS and an MCPBHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment

The respective responsibilities of MHPs, Medi-Cal MCPs, and the Medi-Cal Fee for Service (FFS) delivery systems has not changed
with the adoption of CalAIM. Services for symptoms or conditions solely due to a medical condition (e.g., traumatic brain injury)
remain the responsibility of the MCP or the FFS delivery system.
Additionally, while both MCPs and MHPs are able to provide mental health services to beneficiaries, the level of care andimpairment for a BHRS beneficiary is typically identified as “severe” versus the “mild to moderate” criteria that supports theprovision of non-specialty mental health services (NSMHS) by an MCP. Because a beneficiary’s needs and condition may requirea transition from one level of care to another, coordination of care between the MHP and the MCP has long been best practice.
What has changed under CalAIM is the ability of providers in each system to better coordinate care with each other for the same
beneficiary.

Specialty Mental Health Services (SMHS)

Non-Specialty Mental Health Services (NSMHS)

Specialty Mental Health Services (SMHS) provided to MediCal beneficiaries by BHRS SMHS programs include but are notlimited to:

Non-Specialty Mental Health Services (NSMHS) are delivered
by MCPs and Medi-Cal Fee-for-Service (FFS) providers andinclude the following:•

Assessment•

Plan Development

Diagnosis•

Rehabilitation Services

Problem List•

Therapy Services

Care Planning•

Collateral•

Medication Support Services•

Discharges and Transfers

Targeted Case Management•

Crisis Intervention

Coding Services•

Intensive Care Coordination (ICC)

Progress Notes•

Intensive Home-Based Services (IHBS) and•Therapeutic Behavioral Services (TBS).

Additional Assessment Tools

Coordination of Care

Appendices•Mental health evaluation and treatment, including
individual, group and family psychotherapy•

Psychological and neuropsychological testing, whenclinically indicated to evaluate a mental healthcondition.

•

Outpatient services for purposes of monitoring drug
therapy•

Psychiatric consultation•

Outpatient laboratory, drugs, supplies andsupplements

A – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

Page 67 of 114

Concurrent Care
BHRS Documentation
Manual for SMHS

Under “No Wrong Door,” beneficiaries may concurrently receive NSMHS via a FFS or MCP provider and SMHS via BHRS when theservices are clinically appropriate, coordinated and not duplicative. When a beneficiary meets criteria for both NSMHS and
SMHS, the beneficiary should receive services based on beneficiary clinical need and established therapeutic relationships.

Table of Contents
Introduction

BHRS

MCP

Compliance

SMHS

NSMHS

Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools
Diagnosis
Problem List
Care Planning
Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix

This means that a beneficiary can continue to receive services from a provider in one system if they have an establishedrelationship with that provider, as long as services are coordinated and non-duplicative. For example, a beneficiary may only
receive psychiatry services in one network, not both networks; or a beneficiary may only access individual therapy in one
network, not both networks.
In other words, No Wrong Door allows flexibility for clinically appropriate and nonduplicative concurrent care between the twosystems, However, this does NOT mean that an individual who meets criteria for NMHS can choose to be exclusively seen by
BHRS, or that an MCP must be the exclusive provider for an individual who meets criteria for SMHS. Individuals should still beseen by the appropriate service delivery system for which they meet medical necessity.

Transitioning Care Between the MCP and MHP
BHRS staff must coordinate with MCPs to facilitate care transitions and guide referrals for beneficiaries receiving SMHS totransition to a NSMHS provider and vice versa, and make good faith efforts to ensure that the referral loop is closed, and thenew provider accepts the care of the beneficiary. For more specific information regarding requirements of the Closed Loop
process, see the “Closing the Loop” subsection of the “Discharges and Transfers” section of this manual.
When transitioning care between BHRS and an MCP, the Transition of Care Tool should be used. For more specific information
about the Transition of Care Tool process, see the “Transition of Care Tool” subsection of the “Discharges and Transfers” sectionin this manual.

B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

Page 68 of 114

DISCHARGES AND TRANSFERSBHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools
Diagnosis
Problem List
Care Planning
Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

For transfers that involve a change in level of care andfor all discharges, a brief progress note using code 55(unclaimable) documenting the discharge or transfer
should be written AND a “Reassessment” or“Reassessment Update” should be completed to
document the reasons for the transfer or discharge inmore detail. Most importantly, if there was a change inthe beneficiary's level of functioning, symptoms, etc.
include those elements that led to the decision todischarge or transfer. This includes beneficiaries
transitioning from a program’s mild-to-moderate episodeto the program’s SMHS episode.

A Reassessment /Reassessment Update MUST be Completed
when Discharging a Beneficiary or Transferring a Beneficiary toa higher or lower level of care.
Use clinical judgement to determine which type of reassessment
form is most appropriate to document the beneficiary’s progressor changes in circumstance that led to the discharge or transfer
decision.
It is NOT sufficient to ONLY document the reason for discharge/transfer in a progress note or Transfer Discharge Request Form.

Discharge documentation should include a review of how the person can continue to receive any necessary support if there is aclinical need for ongoing care. Information contained in discharge documentation and shared with the person in care includes:
 How the person’s needs may be addressed, information on prescribed medications, available community services
 The type of care the person is expected to receive and by whom, information on crisis supports
Additionally, a CANS and/or PSC-35 must be completed at discharge for those beneficiaries who fall within the age range foreach tool. Please see the Additional Assessment Tools section of this manual for clarification on the age-ranges for these tools.

WHY DO I NEED TO COMPLETE A REASSESSMENT?
Completing a reassessment at discharge or when changing level of care is bestpractice because it provides a clear and standardized way for providers to
document the reasons for a beneficiary’s discharge or transfer. Additionally, for
Avatar users, once the Transition Tool from is implemented in Avatar, theinformation from the reassessment will populate into the Transition Tool to help
streamline additional documentation that is required for those beneficiaries
transitioning to an MCP. This was done to reduce the burden on staff to retype
critical information that was already included in the assessment.

LINK FROM ASSESSMENT TO
TRANSITION TOOLFor Avatar users the Transition Tool
form in Avatar will be populated fromthe most recent assessment/reassessment form that wascompleted.

FOR AVATAR USERS – TRANSFER/DISCHARGE REQUESTAll programs using Avatar for clinical documentation should complete the “Transfer/Discharge Request” form when discharging
or transferring a beneficiary to a different program or delivery system.
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Transition of Care Tool
BHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools
Diagnosis
Problem List
Care Planning
Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

Page 70 of 114

Closing the Loop
BHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment

Coordinating care between transferring providers and making a good faith effort to ensure that a beneficiary is successfully
connected to the next provider is an essential component of transitioning care.

“CLOSING THE LOOP” FOR ALL TRANSFERS /TRANSITIONS
If the beneficiary is in need of services at a lower level of care, it is not sufficient to simply provide the beneficiary with thephone number to the Access Call Center.
Staff should make a good faith effort to ensure that the client is successfully referred and connected to a lower level of care. This
includes coordinating beneficiary care services with the referred provider to facilitate care transitions or addition of services. The
Closing the Loop process includes, but is not limited to, ensuring that: All appropriate consents were obtained and in accordance with accepted standards of clinical practice The beneficiary understands that a referral has been placed on their behalf.
 The beneficiary is updated on the status of the referral The referral process has been completed

Additional Assessment Tools

 The new provider accepts the care of the beneficiary

Diagnosis

 The beneficiary has been connected with a provider in the new system or program

Problem List

 Medically necessary services have been made available to the beneficiary

Care Planning

REFERRALS TO EXTERNAL PROVIDERS

Coordination of Care

If a beneficiary does not meet criteria for SMHS but would benefit from some care at the lower level, the beneficiary may bereferred to:

Discharges and Transfers
Coding Services
Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix•

One of BHRS’s MCPs if the beneficiary is also an MCP member•

The beneficiary’s private health plan if they have private insurance available to use•

Another appropriate provider (e.g., community based organization that offers sliding scale fees, etc.)

If a beneficiary does not meet criteria to receive any behavioral health service at any level of care, or the beneficiary refuses areferral to another provider, then no referral needs to be made. Staff should document this information in the beneficiary’s
chart and discharge the beneficiary.

B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

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SERVICES THAT CAN BE PROVIDED DURING THE “CLOSING THE LOOP” PROCESSBHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment

If a beneficiary does not meet criteria for SMHS, staff should makegood faith efforts to ensure the referral loop is closed.
To support efforts to “close the loop” on referrals, limited casemanagement services may be provided to support the beneficiary’s
connection to non-SMHS. Staff should use their clinical judgment
and assessment of case management needs to determine whattypes of case management services and for how long they should be
provided during the transition.
In other words, while staff should provide some case management
services, staff do not need to provide case management services
indefinitely until the beneficiary is successfully connected, nor dothey need to provide case management services to a beneficiary if
the beneficiary declines this service.
Staff are not required to provide other treatment services while thebeneficiary awaits a full transition of care.

REIMBURSEMENT OF SERVICES
POST-ASSESSMENT
While all clinically appropriate service arereimbursable during the assessment phase,services that are provided after access criteria
and medical necessity is determined must be
medically necessary in order to be reimbursed
by Medi-Cal.
In other words, after the completion of theassessment, SMHS (outside of casemanagement) that are provided to an individual
who does not meet criteria for SMHS will not be
reimbursed by Medi-Cal.

Additional Assessment Tools

BARRIERS TO “CLOSING THE LOOP”

Diagnosis

There are many reasons a referral may not result in a beneficiary ultimately being connected to services – for example, thebeneficiary changes their mind about wanting services, the beneficiary is difficult to contact, the referred provider is difficult tocontact, etc.

Problem List
Care Planning
Coordination of Care
Discharges and Transfers

The expectation is not for staff to convince all beneficiaries to accept offers of referrals, or for staff to provide services
indefinitely to beneficiaries for whom SMHS is not appropriate. Rather, the expectation is for providers to make a good faitheffort to ensure that the beneficiary was successfully referred and connected to services.

Coding Services
Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

Page 72 of 114

Below are some common issues and clarification of staff roles in these situations.

BHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity

Barrier to “Closing the Loop” – Insurance Issues
BHRS is not responsible for completely resolving an individual’s insurance
issues. However, staff should provide the individual with information on
who they can contact to help them resolve their insurance issues. For
instance, if the individual needs support with Kaiser, staff should direct
the beneficiary to Kaiser so that Kaiser can help them resolve any Kaiserrelated insurance issues. Staff may offer to call Kaiser with thebeneficiary to help “get the ball rolling” on the situation.
If an individual is not eligible or does not want to be connected to the
MCP (for instance, they prefer to use their employer’s insurance), staff
are not obligated to continue to attempt to enroll or change thebeneficiary’s insurance plan to the MCP.

ADDITIONAL COUNTY RESOURCES
In some cases, BHRS staff can utilize county
resources, such as the BHRS Health Insurance
Outreach & Enrollment Team; however, thescope of these internal resources are limited
and certain criteria must be met to use theservices. If needed, staff are encouraged toreach out to their supervisors to determine if
reaching out to these supports would beappropriate on a case-by-case basis.

Screening Tools

Staff should inform beneficiaries of the process of what they should do ifthey want to resume services once their insurance situation is resolved.

Assessment

Barrier to “Closing the Loop” – Not wanting to be referred out

Additional Assessment Tools

If a beneficiary does not or no longer meets criteria for SMHS, but they express a desire to receive services through BHRS rather
than through, for instance, an MCP, BHRS staff are not obligated to accommodate this request. Rather, staff should work withthe beneficiary to educate them on the reason for the referral, and may offer to do a warm handoff or provide casemanagement services for a limited time during the transition.

Diagnosis
Problem List
Care Planning
Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes
Appendices

WHAT IF I WANT TO PROVIDE ADDITIONAL TREATMENT WHILE A BENEFICIARY IS AWAITING TO RESOLVE THEIR
INSURANCE ISSUES OR I WANT TO PROVIDE ONGOING TRANSITION SERVICES AFTER THEY ARE CONNECTED TO THE
NEXT PROVIDER?
In most cases, this would not be appropriate because it has been determined that the beneficiary does not meet medical
necessity criteria for SMHS. If staff believe that it would be clinically appropriate to continue to provide services beyond thestandard transition case management services, the decision should be made at the higher level. Talk to your supervisor todetermine the process for getting approval in these special cases.

A – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

Page 73 of 114

CODING SERVICESBHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment

Under CalAIM, part of the changes include how counties are reimbursed for services. DHCS refers to this as Payment
Reform. One important objective of payment reform is to align with other healthcare delivery systems and comply with CMS(Centers for Medicare & Medicaid Services) requirements for all state Medicaid programs to adopt Current Procedural
Terminology and Health Care Common Procedure Coding System. We commonly refer to these as CPT and HCPCS codes. CPT
and HCPCS codes are the standardized medical billing across disciplines and practice types, allowing for a wide range of healthcare professionals, including mental health. The internal service codes that are currently being used by BHRS staff are included in
the Service Code Cheat Sheet.

Prior Authorization
Prior Authorization is a process that requires beneficiaries to get approval for a health care service or medication before it canbe provided. Please see the table below for outpatient services for which DHCS requires prior authorization and those which
DHCS has stated that prior authorization shall not be required.
Prior Authorization Required

Additional Assessment Tools
Diagnosis
Problem List
Care Planning
Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

Required by DHCS
 Intensive Home-Based Services (IHBS)
 Therapeutic Foster Care (TFC) Day Treatment Intensive
 Day Rehabilitation
 Therapeutic Behavioral Services (TBS)The services above are the outpatient services that are referenced inmost DHCS Behavioral Health Information Notices when “outpatient
services that require prior authorization” are mentioned. There areother services within BHRS that require authorization for utilization
management purposes but do not fall under the DHCS definition of a
SMHS outpatient service that requires “prior authorization.”

No Prior Authorization Required
DHCS stipulates that prior Authorization shallNOT be required for the following services.








Crisis Intervention
Crisis Stabilization
Mental Health Services, including initialassessment.
Targeted Case Management
Intensive Care Coordination
Peer Support Services
Medication Support Services

For services where no prior authorization is required, there may be other care planning requirements that must be completed inorder to provide the service. For example, TCM, PSS and ICC have care planning requirements but do not require a “priorauthorization.” Please see the Care Planning section of this manual for more detail.
For information on how to request services that require authorization (prior or otherwise), please contact your programsupervisor.
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Service Codes
BHRS Documentation
Manual for SMHS

For a list of available service codes, check the BHRS Service Code Cheat Sheet on the QM Website: www.smchealth.org/bhrs/qm

Location Codes

Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools
Diagnosis
Problem List
Care Planning
Coordination of Care

General Information
A location code is where the service is provided or received. Location Codes allow for the provider to specify where a service wasconducted and are included in claims (billing). There are multiple categories and modalities of location codes, and which codes
to use depends on a variety of factors, which will be explained later on in this section of this manual.

GENERAL TYPES (USED TO SPECIFY MODALITY) In-Person Location Codes Remote Services Location Codes (audio-only or videoconferencing)
GENERAL CATEGORIES RELATED TO BILLING Billable Non-Billable (Blocked from Billing)o Lockouto Partial Block

Determining Location CodeBlocked Billing Location Codes(“LOCKOUT” and “PARTIAL BLOCK”)
always supersede other location codes.
Please see the location code index for
information on which locations areblocked from billing.

Discharges and Transfers

Location Code Index

Coding Services

Please see the Location Code Index located on the QM Website for a full list of all the location codes used within the BHRS
system. The Location Code Index also notes which locations are considered “Lockout” locations or “Partial Block” locations.

Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

Definition of “Home”“Home” is a location, other than a hospital or other facility, where the patient receives care in a private residence.
This does not have to be a “traditional” home such as a single-family home or apartment. It can be a hotel, encampment, etc.
as long as it is where the beneficiary resides AND is not a hospital or other facility, a location for which another code would be
more appropriate (e.g., Homeless shelter, residential care, or skilled nursing facility), or a lockout location.
Page 75 of 114

Remote Services Location Codes
BHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance

About Remote Services
Remote Service delivery includes services that are provided to the beneficiary when the provider andbeneficiary are not in the same physical location unless the beneficiary is in a lockout location. If it is alockout location, then use the lockout location code. Remote services have been available for quite sometime but have become more commonly used in recent years. BHRS has updated its policies to reflect
new/updated state and federal regulations that have been created to account for this increase in usage.

Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools
Diagnosis
Problem List
Care Planning
Coordination of Care

RELATED POLICIES TO REVIEWFor more on appropriate use of cell phone, text
message, and email use with beneficiaries, review thefollowing policies.
Please note that there are additional policies not listed
below that may be related to a particular population,
program, or situation.

Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024•

You must obtain consent from the beneficiary (BHRS Policy
22-07) before providing services remotely and/or before
engaging in electronic communication with the beneficiary(e.g., text, email).

•

It is best to use email and text to communicate nonsensitive information, such as to schedule appointments.
Email and Text may be used to communication with
beneficiaries in some cases but should NOT be used as theplatform to provide therapy services.

•

This applies whether the service is provided in-person or
remotely.

Policy 22-06: Electronic Communication (General
Guidelines)
Policy 22-07: Electronic Communication (forCommunication with Clients)

Discharges and Transfers
Coding Services

SPECIAL CONSIDERATIONS FOR REMOTE SERVICE
DELIVERY

Definition of “Home” for Remote Services
The definition of “Home” used for the Remote Services Location codes is the same as described in the previous section. Take alook at the full list of location codes if you aren’t sure if you should select “Telehealth Home” or “Phone - Client at Home.” If
there is a location code other than “Home” that better describes your beneficiary location, then you would NOT select“Telehealth Home” or “Phone - Client At Home.”
Remote Services labeled as “Home” refer to when the beneficiary is receiving services, not when a service is being provided to acollateral or other professional without the beneficiary present. For example, if the beneficiary is at home in their room while
staff is speaking on the phone to the beneficiary’s mother who is in the kitchen, the location code “Phone – Non-Client Contact”
Page 76 of 114

would be used. However, if the beneficiary is in the kitchen participating in the phone call with their mother, then “Phone –Client at Home” would be used.

BHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity

Remote Location Code Index
The following location codes should be used when providing services remotely UNLESS the beneficiary is in a lockout location(e.g. jail, PES/Psych Hospital). If it is a lockout location, then use the lockout location code.

Location CodeModality of Service

TelehealthVideoconferencing (withbeneficiary)• When you have a visual of beneficiary while using a videoconferencing application.

Telehealth Home

Videoconferencing (withbeneficiary)

Phone - Non-Client Contact

Phone (without
beneficiary)• When you have a visual of beneficiary while using a videoconferencing application AND the beneficiary is at home.
• If you are using a video conferencing application but CANNOTsee the beneficiary (e.g., beneficiary has turned their cameraoff), this should instead be coded as “Phone” since you are
only able to engage in audio-only communication with thebeneficiary.
• When you are speaking to a collateral over-the-phone or overvideoconference.
• When you are speaking to another provider over-the-phoneor over videoconference.

Screening Tools
Assessment
Additional Assessment Tools
Diagnosis

Videoconferencing(without beneficiary)

Problem List
Care PlanningPhone - Client At Home

Phone (with beneficiary)

Discharges and Transfers

Phone - Client Not At Home

Phone (with beneficiary)

Coding Services

Voicemail/Fax/Email

Voicemail, Email, Fax, Text

Coordination of Care

Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix

Examples• When you are speaking with the beneficiary over-the-phone
without video and the beneficiary is at home.
• When you are speaking with the beneficiary over-the-phone
without video and the beneficiary is not at home.
• Services provided using these methods is NOT billable.
• Please remember that texting and/or emailing are notappropriate methods to deliver behavioral health services. If
you believe you have a situation that warrants the use of
text/email to deliver services, contact your supervisor and
BHRS QM.

B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

Page 77 of 114

Blocked Billing Locations and Non-Reimbursable Services
BHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment

All staff must understand how services are claimed and know that some services are not claimable. In general, progress notes
using billable service codes are included in claims to be reimbursed by Medi-Cal. However, there are some situations in which
services will not be reimbursed. These situations include:
1) When a service is provided in a location that does not allow BHRS
to bill for outpatient services, even though a billable service code is
used.

DOCUMENTATION REMINDER

There are two types of location codes that block billing: “Lockout”
and “Partial Block” location codes.

LOCKOUT and PARTIAL BLOCK location codes
always supersede other location codes.

2) When a service does not fit the description of a billable service.

When using a blocked billing location code,
you should still use the service code that mostaccurately describes the service you provided.

Services that do not fall into a billable service type should not use
billable service codes; staff should instead use non-billable service
codes.

Non‐reimbursable service codes and blocked billing location codes prevent the service from being inappropriately billed.

Additional Assessment Tools
Diagnosis
Problem List
Care Planning
Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

Blocked Billing Location Codes (Type 1) – Lockout
Lockout location codes indicate that all services provided
using these lockout location codes are blocked frombilling, meaning they will not be sent to claims because
they are not reimbursable by Medi-Cal.

“LOCKOUT” VERSUS “LOCKED”

Once a lockout location is entered, our information
system will “lock out” (or “block’) the claim from billing.
For a list of all lockout location codes, please reference
the Location Codes Index on the QM Website.

A LOCKOUT location is a location that is blocked frombilling.

There are two types of situations that indicate a“lockout,” which would ensure that any services provided
while the beneficiary is in the lockout situation is notinappropriately billed to Medi-Cal.
See then next page for more information regarding these2 types of lockout situations.

A “locked” facility is not the same as a “lockout” location.

A LOCKED facility describes a facility that is closed andlocked, meaning that entry and exit from the facility is
physically locked and visitors and beneficiaries must be
checked in and out of the facility.
A locked facility is often either a lockout location OR apartial block location.

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LOCKOUT SITUATIONSBHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools
Diagnosis
Problem List
Care Planning
Coordination of Care
Discharges and Transfers

1) Lockout Location code that indicates an unbillable manner in which a service was provided.
For example, sending an email or leaving a voicemail would be unbillable even if a service, such as leaving information about
a community resource, was provided. Missed visits fall under this type because a service was unable to be provided in any
manner and is therefore unbillable.
2) Lockout Location code that indicates the placement location of the beneficiary that prevents claiming for outpatient
services.
Lockouts based on the placement location of a beneficiary only block claiming for services by outpatient providers (who areemployed outside of the facility) providing services to an individual placed at that facility. For example, in PES, lockout does
not apply to PES staff but does apply to a BHRS outpatient clinic staff providing services for a beneficiary while they are a PES
patient.

Blocked Billing Location Codes (Type 2) – Partial Block
While locations that are considered “lockouts” block all services from being billed, there is another type of blocked billing
location type that allows for some, but not all, outpatient services to be billed. These are called “Partial Block” location codes.
[Examples of locations considered “Partial Block” location codes are available in the Location Codes Index located on the QM
Website.]When staff select a “Partial Block” location, the BHRS information system will automatically determine which services to “block”
from billing and which services should be passed on to claims for reimbursement.
Whether or not an outpatient service is billable while the beneficiary is located in these Partially Blocked locations depends on
two factors:
When the Service was Provided

Coding Services

Most outpatient codes cannot be billed on the same date of service as residential codes or on the same day as a
psychiatric health facility service except on the dates of admission or discharge.

Progress Notes

Which Services were Provided

AppendicesDepending on the facility type and provider type, only certain outpatient SMHS may be billed to Medi-Cal while
also being provided services through the facility.

A – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

FOR STAFF WHO PROVIDE NON-MEDICATION SERVICES
On the next page is a table of the types of services which are allowed based on Partial Block facility type for non-medication
services (e.g., case managers, peers support specialists, therapists). All services provided must be medically necessary. Peer
Support Specialist Services include only those services that may be provided by certified Peer Support Specialists.
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BHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment

Only billable on date of
Admission or Discharge

Any Outpatient SMHS

Case Management

Peer Support Specialist
Services

Psychiatric Hospital

Yes

Yes

Yes

Residential Care – Adults(Licensed Community Care Facility)(Locked)

Yes

Yes

Yes

Residential Care – Adults(Licensed Community Care Facility)

Yes

Yes

Yes

Partial Block Location

FOR STAFF WHO PROVIDE MEDICATION SERVICES
The only Partial Block location that blocks the billing of medication services is a psychiatric inpatient facility.

Additional Assessment Tools

Only billable on date of
Admission or Discharge

Diagnosis
Problem List
Care Planning

May be billed in between Admission and Discharge Dates
Any service that is not listed below is NOT billable.

Partial Block Location
Psychiatric Hospital

May be billed in between Admission and Discharge Dates

Any Outpatient
SMHS

Medication
Support Services

Other Medication Services(e.g., Medication Injection/Administration)

Yes

No

No

Coordination of Care
Discharges and Transfers
Coding Services

Non-Billable Service Codes

Progress Notes

DIRECT BENEFICIARY CARE UNCLAIMABLE (55) AND UNCLAIMABLE GROUPS (550)

Appendices

These codes are used for services provided to beneficiaries and their families thatare not claimable to Medi‐Cal. These services include the wide variety of services
deemed necessary for recovery and resiliency, but are not reimbursable as mental
health or other claimable services. This category is intended to permit flexibility intreatment planning on the part of clinical teams and to promote the adoption ofrecovery‐based services to beneficiary beneficiaries. These services may be
documented by all members of the clinical teams working with beneficiaries.

A – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

55

550

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Non-Billable Services
BHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements

The following are examples of activities that are not claimable for reimbursement (do not claim if these are documented; use
one of the non‐reimbursable codes, 55 or 550, or enter the time in the “Other non-billable time” field of the progress note) Reviewing or preparing chart for assignment oftherapist, to close a chart (discharge note) or for
release of information
 Closing a chart (transfer of case could be CaseManagement or Plan Development) Any documentation after beneficiary is deceased

Access to SMHS and Medical
Necessity Preparing documents for court/testifying/waiting in
court

Screening Tools

 Letter excusing beneficiary from jury duty/testifying,waiting in court

Assessment
Additional Assessment Tools
Diagnosis
Problem List
Care Planning
Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

 Listening to or leaving voice mail or email
message and sending/receiving faxes or emails
 Mandated reporting such as CPS/APS/Tarasoff
reports
 No service provided: missed visit. Traveling to asite/waiting for a “no show”. Documenting that abeneficiary missed an appointment.
 Leaving a note on a door, or a message on ananswering machine or with another beneficiary about
the missed visit.
 Personal Care services provided to beneficiaries
including grooming, personal hygiene, assisting with
self‐administration of medication, meal prep Assistance provided to family members
seeking needed services for him/herself

 Purely clerical activities (faxing, copying, filing,
mailing...etc.)
 Scheduling/re‐scheduling appointments
 Recreation or general play (e.g. teaching beneficiary
how to play a sport)
 Socialization: generalized social activities which do
not provide individualized feedback related to mental
health diagnosis
 Walking groups, smoking cessation groups, etc.
 Academic/Educational services: Assisting beneficiarywith homework, teaching math or reading...etc.
 Vocational services for the purpose actual work or
work training. (Exception: VRS services clearly linked
to mental health diagnosis)
 Supervision: Supervision of clinical staff or trainees is
not reimbursable
 Utilization management, peer review, or other quality
improvement activities
 Interpretation/Translation only (without a billable
service) Transportation of a beneficiary Preparation for a service—e.g., set up for grouptherapy
 SSI paperwork with no beneficiary present
Page 81 of 114

Sometimes a service might look like a reimbursable service when, in fact, it is not reimbursable, or vice versa. The key is to lookat what service was actually provided and if the focus of the service meets medical necessity criteria.

BHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity

The following are examples that demonstrate when the actual service provided during the course of a seemingly simple activity
actually results in vastly different answers to the question: “Is this a reimbursable service?”

Short Description of Activity

Academic/Education Situation
Sitting in a classroom with thebeneficiary.

Recreational Situation

Additional Assessment Tools
Diagnosis
Problem List
Care Planning
Coordination of Care

Going to a community location
together.
Vocational Situation
Interacting with the beneficiaryat their work place.

Coding Services
Progress Notes

Accessing Resources Situation

AppendicesMeeting with the beneficiary
to fill out paperwork forhousing.

B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

NO, this is NOT Reimbursable

YES, this IS Reimbursable

Assisting the beneficiary with his/herhomework.
OR

Sitting with the beneficiary in a community
college class to help reduce the beneficiary’s
anxiety and then debriefing the experience
afterward.

Teaching the beneficiary how to lift
weights.

Introducing a beneficiary to a Friendship Centerand debriefing about the visit.

Visiting the beneficiary’s job site to teachthem how to cook hamburgers.

Responding to the employer’s call forassistance when a beneficiary is in tears atwork because they are having trouble learning
to use a new cash register is reimbursable if the
focus of the intervention is assisting thebeneficiary to decrease their anxiety enough toconcentrate on the task of learning the newskill.

OR
Teaching a beneficiary how to use a cash
register.

Discharges and Transfers

A – Service Code, Location
Code, Time Field Matrix

Detailed Description of Service

Teaching a typing class at an adultresidential treatment program.

Screening Tools
Assessment

Detailed Description of Service

Staff waits while the beneficiary fills out
the forms.
OR
Staff fills out the form for beneficiary,
periodically asking beneficiary to provide
information for the form.

Beneficiary reports that they are unable tocomplete paperwork due to high level ofanxiety about writing down the “wrong”
information. Staff sits with beneficiary andcoaches beneficiary to use relaxation
techniques and cognitive coping to support
beneficiary’s ability to work through theiranxiety to complete paperwork.
Page 82 of 114

PROGRESS NOTESBHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools
Diagnosis
Problem List
Care Planning
Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes
Appendices

General Information
Progress notes are an essential component of clinical work. They serve as a legal record of the services provided to a beneficiary.
It is the legal and ethical duty of all providers to write clear, complete, and accurate progress notes after every service provided
to or on behalf of a beneficiary. If it’s not documented in writing, it did not happen.
Additionally, progress notes serve as bills to various funding sources which provide reimbursement for the services provided toour beneficiaries. These funding sources verify that adequate and timely progress notes are written for the services provided
and that the progress notes include all required elements, have sufficient content, and are legible and signed by the service
provider. The content of progress notes should be easily understandable, without requiring additional context or information,and should provide a clear ongoing record of the beneficiary’s condition, clinical interventions and intended next steps.
Progress notes are also an essential way to facilitate communication and coordination of care between providers and are readby other treating providers to better understand the beneficiary’s condition, needs and course of treatment. It is important toremember that progress notes may also be read by the beneficiary or their family members, and that progress notes may be
used in legal proceedings.
Please note that the information included in a progress note may vary basedon the service type and the beneficiary’s clinical needs. Some notes may
contain less descriptive detail than others. If information is located elsewherein the clinical record (for example, the Assessment or Treatment Plan), it does
not need to be duplicated in the progress note. Use clinical judgement todetermine if the information is adequately provided in another area of the
medical record.
The following sections highlight important aspects of progress notes in further
detail. If you ever have questions regarding the content of your progress noteor other documentation related questions, please reach out to your supervisor
or BHRS Quality Management for support.

DOCUMENTATION REMINDER
Certain information should never be
included in a progress note, such as
information about a grievanceinvestigation or a critical incident reportinvolving the beneficiary.

A – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

Page 83 of 114

Timeline for Documenting Services
BHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools
Diagnosis
Problem List
Care Planning
Coordination of Care
Discharges and Transfers

Providers MUST complete progress notes within three (3) business days of providing a service, with the exception of notes forcrisis services, which MUST be completed within one (1) calendar day. The day the service was provided is considered day zero(0). Progress notes should never be completed in advance of a service.
If a Progress Note is submitted outside of 3 business days, it is good practice to document the reason the note is delayed in the
body of a Progress Note. Late notes remain billable and should not be withheld from the claiming process. However, if yournote is significantly late, please consult with your supervisor or QM to determine the best service code to use. Please note thatstate regulations may require stricter timelines for completing progress notes depending on the program/facility type (e.g.,
STRTP, other DHCS regulations).
•

Crisis services: Documentation should be completed within one(1) calendar day.

•A daily note is required for documentation of some residential
services*oCrisis Residential TreatmentoAdult Residential Treatmento

DMC/DMC-ODS Residential Treatmento

Day Treatment services (including Therapeutic Foster
Care, Day Treatment Intensive, and Day Rehabilitation),and other similar settings that use a daily rate for billing(i.e., bundled services).

Compliance ReminderCompliance within a Medi-Cal context isfocused on ensuring that there is no fraud,
waste, and abuse within the service provisionand claiming system. Disallowances in audits
will occur when there is evidence of fraud,
waste, or abuse. Documenting accurately, in atimely manner and in alignment with theguidelines listed in this guide are necessary
steps to promote compliance.

*In these programs, weekly summaries are no longer required. If a bundled service is delivered on the same day as a second
service that is not included in the bundled rate, there must also be a progress note to support the second, unbundled service.

Coding Services
Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

3

Business Days

Standard
Services1

Calendar Day

CrisisServices

Daily
BundledServices

WeeklyBundledServices
Page 84 of 114

Progress Note Fields
BHRS Documentation
Manual for SMHS

Independent Note vs. New Service
In most cases, “New Service” should be selected when completing a Progress Note.

Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools
Diagnosis
Problem List
Care Planning
Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes

An “Independent Note” is only selected in rare instances when a beneficiary has been discharged from all open episodes and a
progress note must be written to document an event related to this beneficiary. Independent notes do not get billed and do notinclude dedicated data fields to indicate the date of service, duration of service, etc. Staff should write any relevant informationsuch as date, time, location, and type of contact or service that was provided in the body of the note.

Service Time
The Service Time field is used to document timespent providing direct patient care. This includes
time that a provider directly spends with abeneficiary in-person, on the phone, or via videoconference to provide a billable service. Direct
patient care also includes time spent with thebeneficiary’s support persons or otherproviders/care team, to deliver a billable service.

DOCUMENTATION REMINDER
Direct patient care does not include travel time, documentation,
administrative activities, chart review, utilization review, quality
assurance activities or other activities a provider engages in either
before or after a beneficiary visit.

For information on Service Codes please see Service Code section of this Documentation Manual.

Service Duration
Avatar NX auto-populates the Service Duration time with the same minutes that are inputted into the Service Time field. This isbecause the Service Duration field does not include documentation/travel time/other billable service time. DO NOTUPDATE/CHANGE THE TIME THAT AVATAR NX AUTO-POPULATES IN THE “SERVICE DURATION” FIELD. The function of this field
is primarily for the billing department.

AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

Other Non-Billable Time
This field should be used to enter time spent providing services that do not fall into the categories of service time,
documentation time or travel time. For instance, time spent talking with a beneficiary to schedule an appointment would be
included here. For a list of Non-Billable Services, please see the Coding section of this Documentation Manual.
Page 85 of 114

Documentation and Travel Time
BHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools
Diagnosis
Problem List

Under CalAIM Payment Reform, DHCS no longer directly reimburses for time spent on non-direct patient care, such as
documentation and travel time.
However, in an effort to streamline claims processing, DHCS has updated their reimbursement rates for direct patient careservices to account for documentation and travel time. Time spent on travel and documentation should still be recorded in therespective fields of the Progress Note form in Avatar, as this information may be used for future rate setting.

DOCUMENTATION TIME
Refers to time spent writing. These services are not considered direct patient care. Some examples include: Time it takes towrite a progress note, time to write up an assessment or treatment plan without the beneficiary’s participation, any time spent
documenting where you are not providing a direct service to the beneficiary.

TRAVEL TIME
Refers to the time spent traveling round-trip to provide a billable service. All travel time is applicable when it is tied to a billable
service provided directly to the beneficiary or on the beneficiary’s behalf, including to the beneficiary’s support persons or withother treating providers.
Below is a guide to help you understand when it is generally acceptable to include travel time in the “Travel Time” field in a
progress note:

May I Include Travel Time in the “Travel Time” field?
Travel from your usual worksite to another clinic to provide a billable service

Yes*

Travel from your usual worksite to community location to provide a billable service

Yes*

Travel from your usual worksite to client’s home to provide a billable service

Yes*

Discharges and Transfers

Travel between multiple clinics in a day to provide billable services

Yes*

Coding Services

Travel from your personal residence to your usual worksite at the start of your workday

No

Progress Notes

Travel from your usual worksite to your personal residence at the end of your workday

No

Appendices* Not ALL the time spend traveling is allowed to be included in the “Travel Time” field. The next page includes additional
instructions on how to determine the amount of time that is allowed to be included in the “Travel Time” field.

Care Planning
Coordination of CareA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

Page 86 of 114

Determining the Amount of Time To Include in “Travel Time”

BHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools

The time it would usually take you to commute to and from your regular worksite is not considered travel time. However,there may be some scenarios where you would document travel time when traveling from or to your personal residence atthe start or end of your workday.
Travel time should NOT be included in a progress note if it took you less time to travel to or from your appointment than it
would have from your regular worksite.
For Example:•••

Usual travel time from your personal residence to your regular worksite = 20 minutes
Travel from your personal residence to a beneficiary’s home for your first appointment of the day = 10 minutes
This travel time would not be included in the progress note because it is less than what your usual commute time
would have been to your regular worksite.

•••

Usual travel time from your personal residence to your regular worksite = 20 minutes
Travel from your personal residence to a beneficiary’s home for your first appointment of the day = 35 minutes
Only add 15 minutes of travel time to your progress note (you can only claim the travel time that was in excess of
your usual commute time).

••

Usual travel time from your regular worksite to your personal residence = 20 minutes
Travel from an appointment at a beneficiary’s home to your personal residence at the end of your workday = 30
minutes
Only add 10 minutes of travel time to your progress note (you can only claim the travel time that was in excess of
your usual commute time).

Assessment
Additional Assessment Tools
Diagnosis
Problem List
Care Planning•

Coordination of Care••

Discharges and Transfers•

Coding Services
Progress Notes
Appendices

Usual travel time from your regular worksite to your personal residence = 20 minutes
Travel from an appointment at a beneficiary’s home to your personal residence at the end of your workday = 15
minutesThis travel time would not be included in the progress note because it is less than what your usual commute time
would have been to the office.

A reminder that, if you are traveling to complete administrative tasks, this is not considered Travel Time. This is because
administrative tasks are not billable services. Time spent travelling for non-billable services is not entered into this field.
Instead, please put this time in the “Other Non-Billable” service time category.

A – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

Page 87 of 114

FREQUENTLY ASKED QUESTION ABOUT DOCUMENTATION AND TRAVEL TIMEBHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity

What if the beneficiary no-shows?
Travel time to meet the beneficiary, even if they no-show, should still be documented in the Travel Time category. This isbecause you intended to provide a billable service. When the beneficiary no-shows, include your travel time in the “Travel Time”
category and use the Location Code of “Missed Visit.”
What if I provide a service while transporting the beneficiary? Is this considered Travel Time?
Under certain circumstances, it may be possible to provide billable services while transporting a beneficiary. Use clinicaljudgement to determine whether it is safe and reasonably possible. If you are unsure, please consult your supervisor or reachout to QM for additional support.
If appropriate, you would use the service code that best describes the billable service that you provided and enter the service
minutes to a progress note as follows:•

Service Time: Enter the minutes you spent providing an intervention/billable service while transporting a beneficiary.

Screening Tools•

Travel Time: Enter the minutes of travel time that you spent providing a billable service.

Assessment•

Other Non-Billable Time: Enter any additional minutes you spent transporting the beneficiary while not providing anintervention/billable service.

Additional Assessment Tools
Diagnosis
Problem List
Care Planning
Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes
Appendices

Do you add the Travel Time for Non-Billable Services?
Document travel time related to non-billable services in the “Other Non-Billable Time” category. For example, if you aretraveling to complete administrative tasks, or simply transporting the beneficiary without any therapeutic interventions, this is
not included in Travel Time. Please put this time in the “Other Non-Billable Time” category. For a list of Non-Billable Services,
please see the “Blocked Billing and Non-Reimbursable Services” subsection in the “Coding Services” section of this manual.

Beneficiary (Client) Participation Field
This field asks the question “Did client participate in this service?” Participation as used for this question includes participation
in-person, participation via phone, or participation over a video-conferencing platform. Mark “Yes” if the beneficiary
participated in the session, and mark “No” if they did not participate in the session.

A – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

Page 88 of 114

Collateral Participation Field
BHRS Documentation
Manual for SMHS

Since there are longer collateral-specific service codes, BHRS
Progress Notes include a field titled “Did Collateralparticipate in service?” to allow our system to better
capture the provision of collateral services.

Table of Contents

If the Collateral participated in the service, mark “Yes.” If acollateral did not participate in the service, mark “No.”Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools

A collateral may participate in the service in-person, overthe-phone, or via videoconferencing.

DEFINITION OF “COLLATERAL”
A collateral is a significant support person who supports thebeneficiary in a non-professional capacity. The purpose of acollateral’s participation is to focus on the treatment needsof the beneficiary by supporting the achievement of thebeneficiary’s treatment goals.

Restricted Notes
This section describes the different restricted note types available for BHRS
Avatar NX. Notes in Avatar NX allow staff to indicate when a note should be
restricted and to allow for the tracking of disclosures. Contracted agencies who
use their own EHR may or may not have similar categories for restricted
progress notes.

Care Planning

All notes should be reviewed prior to release, regardless of whether or not thenote is flagged as restricted. Restricted notes indicate that a the writer of thenote determined that a higher level of scrutiny should be applied whenreviewing the restricted note.

Coordination of Care

WHAT MARKING A NOTE AS “RESTRICTED” DOES AND DOES NOT DO:

Diagnosis
Problem List

Discharges and Transfers
Coding Services
Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix

Important Reminder
Do not assume that only notes marked as
flagged contain sensitive information.
There is always the chance that a note
was not flagged to be restricted eventhough it should have been.

 Marking a note as “restricted” serves as a “flag” to let staff know that those notes should be carefully reviewed todetermine if it is appropriate to release to the parties requesting the record.

 Marking a note as “restricted” does NOT automatically remove the notes from being released.
Staff who require co-signature should use the versions of the restricted type that state “(Co-Sign Required).”B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

Page 89 of 114

HOW TO MARK A NOTE AS RESTRICTEDBHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools

BHRS Standard Note

Care Planning
Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes
AppendicesDisclosure Without(W/O) Consent

1) BHRS Standard Note
Selecting this option does not flag a note as restricted. This is the type of progress note for documenting most services.
These notes should be reviewed prior to release, but do not indicate that there is particularly sensitive information in thenote that requires more scrutiny beyond a standard clinical review before release.
2) Restricted – No Disclosure Without Consent
Marking a progress note using this category is how you “flag” a note as restricted. These notes should not be disclosed
unless there is a RELEASE /CONSENT from the BENEFICIARY. Selecting this type for a progress note means information will
be flagged as restricted and the clinician/clinical team will review and determine if release is necessary and if so, get a
release from the beneficiary prior to releasing it. Use ONLY FOR progress notes containing information:•

About HIV status.

•

Given in confidence by a family member/significant support person who requests that it not be shared with thebeneficiary.

•That, if disclosed to the beneficiary, might result in serious risk to the person who provided the material (even if theperson disclosing did not request restriction).

•

If a youth beneficiary requests information in the note be restricted – such as sexual behavior (not abuse), AOD
use/treatment, HIV fears and other private or personal information. Use with caution in these situations.

Diagnosis
Problem List

Restricted - No
Disclosure Without(W/O) Consent

3) Disclosure Without Consent (Not Treatment)
Can be disclosed without a beneficiary release/consent; note does not contain restricted information or information related
to Treatment/Payment or Operations.
Information in this note type can be released without the consent of the beneficiary:•

A – Service Code, Location
Code, Time Field Matrix

To the family/significant other in an urgent, safety/crisis situation (e.g., a current threat of harm to others or deathreporting);•

To the police/other law enforcement;

B – Service Definitions•

To CPS or APS, even if the reporting is mandated by law;

C – Progress Note Templates•

To the DMV for lapses of consciousness.

Last Updated: 10/17/2024

Page 90 of 114

Same Day, Same Service Progress Notes
BHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools
Diagnosis
Problem List
Care Planning
Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions

Same Day, Same Service Decision Tree
Under CalAIM Payment Reform, all claims forthe same beneficiary, that are provided under
the same service code, by the same provider,on the same day, MUST be combined into
one progress note. If you provided multiple
services to THE SAME CLIENT, ON THE SAME
DAY, please follow the decision tree to theright to determine if you should combine allnotes written on that day into one note.
Example: A clinician provides 14 minutes ofCase Management services by phone and 17
minutes of Case Management services at theoffice, on behalf of the same beneficiary, on
the same day. The clinician should complete
one progress note for all Case Management
services provided and select the location as“Office”.
Note: Services that were provided in different
locations but were provided on the same day
using the same procedure code by the sameprovider must be combined. The place ofservice where the majority of the service
occurred should be reported. Within the bodyof the progress note, document that theservice was provided in two different
locations.

Were Services provided
on the same day?

Yes

No

Were the services provided
by the same staff person?

Yes

Write Separate Notes.

No
Services provided bydifferent staff should NOT
be combined into one note.

Were the services provided
to the same client?

Yes

No

Were the services the same
type of service (using same
service codes*)?

Yes

Combine all these
services into one note.

Services provided todifferent clients should NOT
be combined into one note.

No
Notes that use different
service codes should NOT
be combined.

C – Progress Note Templates
Last Updated: 10/17/2024

Page 91 of 114

Individual Progress Notes
BHRS Documentation
Manual for SMHS
Table of Contents

Progress Notes for Individual Services (non-group) should include the following minimum elements:
 Type of service provided
 Date of service provided

PROGRESS NOTE TEMPLATES Duration of direct service provided

Please use the progress note templates
provided in Avatar to assist you with including
all the required elements of a progress note.

Introduction

 *Location/place of service

Compliance A typed or legibly printed name, signature of the provider, and dateof signature.

Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools

 A brief description of how the service addressed the client’s
behavioral health needs (e.g., activities or interventions used, any
issues discussed, progress toward goals).
 A brief summary of next steps (e.g., action steps, collaboration
with client or providers, goals, steps to address client’s needs,
referral, discharge planning).

Select the template that best describes theservice you are providing.
The Avatar Progress Note form alreadyincludes some of the required elements indesignated categories, while other elements
are required in the body of the progress note.

 Next Appointment (Include earliest offered appointment date for next appointment).

Diagnosis
Problem List

Co-Practitioner Progress Notes (Non-Group)

Care Planning

The guidance under CalAIM regarding the use of a co-practitioner states that should more than one provider provide a service,
either to a single member or to a group, at least one progress note per member must be completed. The note must be signed byat least one provider. The progress note shall clearly document the specific involvement and duration of direct patient care foreach provider of the service.

Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

As of July 2023, due to changes in the claiming structure that interfered with our ability to correctly bill for co-practitioners ingroup notes, adding a co-practitioner’s services through the co-practitioner field in a progress note is no longer an option in
BHRS' Avatar NX. The Co-Signature section of progress notes was also removed as of October 13, 2023
As a result, in order to successfully bill for services that occurred on or after 7/1/2023, each provider mustcomplete a separate progress note when more than one provider will be billing for the same appointment forany service type (including group) provided to or on behalf of a beneficiary.
Example: When two providers co-facilitate a group therapy session, each provider will submit a separate progressnote for each member of the group, documenting the providers specific role in the group and the specific amount oftime they provided direct patient care.
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Group Progress Notes
BHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity

When a group service is provided, a list of participants is required to be documented and maintained by the provider. Due toconfidentiality standards, the full list of group participants must not be kept in any single beneficiary’s medical record. The“Group Registration Form” found in Avatar NX should be used to record the full list of group members, but the Participant List is
the list of group members who actually attended on a particular day. Participant Lists are required by DHCS.
A new progress note must be written for each group session accurately documenting the events that took place during thegroup that day. It is NOT sufficient to repeatedly copy and paste the same information into each progress note, group after
group.
For each member of the group, an individual progress note must be written in their medical record documenting the service
that was provided to them and their attendance in the group that day. Additionally, progress notes for Group Services should
include the following minimum elements:
 Type of service provided

Screening Tools

 Date of service provided

Assessment

 Duration of direct service provided

Additional Assessment Tools
Diagnosis

 *Location/place of service. (See note under “Additional Requirement for Remote Service Notes” regarding documenting
the location of the client for Remote Services as this also applies to group services provided remotely).

Problem List

 A typed or legibly printed name, signature of the service provider, and date of signature.

Care Planning A brief description of how the service addressed the member’s behavioral health needs (e.g., this may include activities
or interventions, any issues discussed, progress toward goals).

Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

 A brief description of the member’s response to the service (e.g., effectiveness of the intervention, progress or barriers,
other info relevant to member’s participation).
 A brief summary of next steps (e.g., any action steps, collaboration with client or providers, goals, steps to addressclient’s needs, referral, discharge planning).
 When more than one provider is facilitating a group, each provider must describe their (1) specific involvement and (2)their specific amount of time of involvement in the group activity, in each of their respective progress notes. (If there
is only one provider facilitating the group, this information is not required).
 Next Appointment (Include earliest offered appointment date for next appointment).
Under CalAIM, the entire duration of a group should be added to each group participant’s progress note, unless they arrived lateor left early. Please also add the number of clients that participated in the group that day in the designated field in the Mental
Health Progress Note form.
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Co-Facilitated Groups
BHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance

It’s important to note that not every group needs morethan one facilitator.
However, when necessary, each provider mustdescribe their (1) specific involvement and (2) their
specific amount of time of involvement in the group
activity, in each of their respective progress notes
based on the group members’ needs, not theprovider’s needs.

DOCUMENTATION EXAMPLE“An additional facilitator was needed to help manage thebehavioral needs of members in this group and provide support
to the client when they became agitated and required assistancewith implementing coping skills. The additional facilitator actively
participated for the entire group session of 60 minutes.”

Documentation Requirements

Billable Groups vs. Non-Billable Groups

Access to SMHS and Medical
Necessity

BILLABLE GROUPS

Screening Tools

Group services vary based on the primary focus of activities and interventions. Billable groups are structured group activities,
led by a provider, that address the behavioral health needs and goals of the clients in attendance.

Assessment
Additional Assessment Tools

All group providers must be eligible to bill the service type. For example, if the group is Therapy, all group co‐facilitators must beable to provide therapy under their scope of practice and according to billing rules in order to bill for the group session.

Diagnosis

All members of the group must be current clients (or collaterals of current clients) of BHRS or a contractor providing the service.

Problem List

NON-BILLABLE GROUPS

Care Planning

Progress Notes

Non-billable groups are comprised of BHRS beneficiaries (or collaterals of current
beneficiaries), but the service provided in the group does not address the behavioral
health needs and goals of the beneficiaries in attendance. While these groups are
non-billable, they should still be documented via progress notes in the beneficiary’s
chart. For example, a socialization group with no interventions that address the
behavioral health needs of the beneficiary is not billable. For support in determining
if a group is billable or non-billable, please consult your supervisor or contact QM.

Appendices

GATHERING VS. GROUPS

Coordination of Care
Discharges and Transfers
Coding Services

A – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

Some types of gatherings, even if some clients are present, are not charted or billed.
These may include: potlucks or an exclusively social events, community education
class, community outreach event, gatherings in community settings open to the
public, etc. These gatherings are not considered mental health groups as the staff’srole is more of an educator, or the gathering is more of a class or training and not
directly related to the diagnosis and mental health needs of the beneficiary.

DOCUMENTATIONREMINDER
Sometimes, how the progress noteis written can help justify why theservice was billable, if in fact you
believe you were providing abillable service.
Other times, aspects of a groupmay be unbillable and that’s OK!
These services are still verysignificant to the client and theirexperience in the group.
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GROUPS WITH BOTH BILLABLE AND NON-BILLABLE COMPONENTSBHRS Documentation
Manual for SMHS

Some groups might have certain components of the group time that are considered billable, while other components of thegroup time are considered non-billable. Here is a sample group that contains both billable and non-billable components.

SAMPLE NOTE FOR GROUP
Anger Management Rehab Group Provided in Community Location:

Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools
Diagnosis
Problem List
Care Planning
Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

A clinician facilitates a 55-minute combined rehab and socialization group focused on anger management skills for a group ofteen clients. 25 minutes of the group time is spent watching a movie and eating snacks. The other 30 minutes is spent discussing
how to recognize triggers and the basics of anger management coping skills.
Service Code: 70CA Rehab Group
Service Time: 30 minutes (billable service time)
Documentation Time: 8 minutes (time to write the note for one client)Travel Time: 28 minutes (round-trip time from your usual worksite to a community location)
Non-billable Service Time: 25 minutes (time spent watching movie and eating snacks)

Additional Requirement for Remote Service Notes
When providing Remote Services, in addition to the other information outlined in this manual, you must also
include the physical location of the client at the time of the service in the body of each progress note.
While the requirement to include the location of the beneficiary is not a CalAIM requirement, it is arequirement under Division 18 of Title 16 of the California Code of Regulations, which was adopted by the
Board of Behavioral Sciences (BBS) of the Department of Consumer Affairs. This is a requirement that applies
only for services delivered remotely to ensure the safety of the beneficiary during the remote session.

CLINICAL IMPORTANCE OF LOCATION INFORMATION
When providing a direct service remotely, it is best practice for all staff (regardless of whether they are licensed/registered with
the BBS) to ascertain the beneficiary’s location at the beginning of each remote service appointment. This practice ensures thata provider can inform first responders or other crisis support service providers, of the beneficiary’s location, in case of an
emergency, and also ensures that the provider is practicing within their license by confirming that the beneficiary is locatedwithin the State of California. If a beneficiary refuses to provide you with their specific address, staff may use cross streets, or
the general city, county, and/or State in which the beneficiary confirms is their location. If the client refuses to provide any
information, be sure to document the beneficiary’s refusal to provide you with this information. Remember, staff may notprovide services to an individual who is not located in California.
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Documenting Timely Access to Services
BHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools
Diagnosis
Problem List
Care Planning

BHRS is required to meet State standards for timely access to careand services, taking into account the urgency of the need forservices. BHRS must comply with the appointment time standards
set forth in Health and Safety Code (HSC) section 1367.03 and Title
28, California Code of Regulations (CCR), section 1300.67.2.2.
DHCS requires BHRS to have a system in place for tracking andmeasuring timeliness of care, which includes the timeliness of theinitial offered appointment, timeliness to first attended SMHS
appointment, or DMC-ODS appointment, and timeliness of the firstoffered and attended follow-up appointment for beneficiaries who
begin receiving services while waiting for, or are in the process ofcompleting, a clinical assessment.

RELATED POLICIES TO REVIEWThe following policy provides additional information
regarding the requirements to provide timely access toservices.
Please note that there are additional policies not listed
below that may be related to a particular population,
program, or situation.
Policy 18-02: Network Adequacy Standards

CLINICAL IMPORTANCE OF TIMELY ACCESS TO SERVICES
Timely access to services is not simply an administrative, regulatory requirement to gather data. Timely access is critical tohealth care and can increase engagement, improve prognosis, and prevent the need for a higher level of care. Delays in timely
access to care can lead to a variety of negative consequences and experiences for the individual, such as distrust in the system,
health care system, harm to self or others, hospitalizations, etc. that might have been avoided had timely access to care been
provided. Therefore, at minimum, BHRS providers should offer appointments within a reasonable amount of time that meets
Timely Access standards and the needs of the individual. In some cases the needs of the individual may warrant an appointment
sooner than the required timeframe.

Coordination of Care

DOCUMENTING TIMELY ACCESS IN A PROGRESS NOTE

Discharges and Transfers

Providers should include in each progress note the date of the next service that was offered to the client. For instance, if a staff
and beneficiary meet on April 5th and the staff person offers to meet the beneficiary the following week on April 12th, the date ofApril 12th must be documented in the progress note as the next offered appointment. If the beneficiary declines theappointment on the 12th and the staff and beneficiary agree to meet again on April 19th, it is best practice to also include thedate of the agreed upon date of the next appointment in the progress note. Doing so can be beneficial to both the provider andthe beneficiary. For instance, staff can easily verify the date of a beneficiary’s next appointment in a note, if the beneficiary calls
because they forgot their next appointment date, or in case of a missed appointment.

Coding Services
Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

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Tips for Writing Progress Notes
BHRS Documentation
Manual for SMHS

Keep the following in mind when writing Progress Notes:
 Progress notes should be written as if an attorney and/or the beneficiary/family will read them. You should be able toexplain or defend every statement that is made in the progress note. Stay objective and use quotation marks when stating
what other people said.

Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity The content of a Progress Note should be easily understandable, without requiring additional context or information.
Refrain from using clinical jargon, terminology or abbreviations that may not be widely recognized.

 Document the reports made by others involved in the beneficiary’s care and who that information was provided by.

Remember that if it is not documented in writing, it did not happen. You may be asked to describe behaviors or reports
from others at a later date.

 Aim for clarity, brevity, and objectivity when writing notes; lengthy narrative notes are discouraged when documenting
ongoing services.

Screening Tools

 QM has developed templates in Avatar to assist with the writing of Progress Notes. Use a template for every Progress

Assessment
Additional Assessment Tools

Note written, when applicable.

 When writing a progress note that involves another Professional, use the name and role of the professional, for example,
Sally Jones, Probation Officer.

Diagnosis
Problem List When a service is provided to two or more beneficiaries, who are also family members, write a note in each of the client’s
respective charts (split the time accordingly).

Care Planning
Coordination of Care
Discharges and Transfers
Coding Services

Confidentiality in Progress Notes
The medical record is a legal document that may be subpoenaed by a court. Please protect beneficiary confidentiality byfollowing the below standards when completing Progress Notes:

Progress Notes•

Do not write another beneficiary’s name (e.g., classmate or sibling) in any other beneficiary’s chart.

Appendices•In the unusual circumstance that another beneficiary must be identified in the record (for example, when the otherbeneficiary received a Tarasoff warning), do not identify that individual as a BHRS beneficiary.

•

Names of family members/support persons should be recorded only to complete intake registration and financial
documents.

•

On progress notes and most assessments, refer to the relationship ‐ mother, husband or friend, but do not use names.

•

Use a first name or initials of another person only when needed for clarification.

A – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

Page 97 of 114

BHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools
Diagnosis•

Be judicious in entering a mental health diagnosis reported by a parent/spouse/other about themselves or family
members/support persons. (Indicate the entry: “as reported by...”).

•

Limit what you say about family members. Remember, it’s the beneficiary’s chart, not the family member’s chart.

Always keep in mind that you are documenting in the beneficiary’s chart, not in a family member’s chart. Discretion regarding
the inclusion of family members’ or others’ personal information is important to:
1. Protect the privacy of those connected to the beneficiary in treatment
2. Maintain professional ethical standards
3. Prevent potential liability resulting from inappropriate documentation practices

Progress Note vs. Process Note
When you understand the difference between a process note versus a progress note, it becomes easier to write concise notes
and reduce your documentation time which will leave you with more time to provide services to beneficiaries.

Progress Note 
The following items may be included in a progress note: Persons involved (do not include names of nonbeneficiaries in the note).

Problem List

 Interventions used.

Care Planning Plan for next steps.

Coordination of Care

 If a description of a beneficiary’s response is included, it

Discharges and Transfers
Coding Services
Progress Notes

should be brief and include the minimum necessary. Do
not include speculation, opinions, etc. If noting
statements a beneficiary made in session, it is better toquote the beneficiary directly rather than summarize orinterpret the beneficiary’s words in the note.

Process (Psychotherapy) Note 
The following are typically included in process notes andshould NOT be included in a progress note: Detailed narrative of what happened in session.
 Provider’s opinion/analysis of beneficiary’s
behaviors/symptoms in session.
 Provider’s reflections on countertransference, etc.
 Speculation regarding what transpired in session.

AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

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Sample Progress Notes
BHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools

The following Progress Note samples were developed by CalMHSA to support county documentation efforts and are included on
Appendix V of the CalMHSA Clinical Documentation Guide 2023:

ASSESSMENT SAMPLE 1
Met with client for clinical interview to inform the initial intake assessment. Information gathered included the reason(s) for
seeking treatment, current mental state, history of the presenting problem, and impairments caused by the problem. Assessed
the client’s experience of trauma, behavioral health history, substance use disorders, medical history, current medications, andhow their culture, religion, and spirituality influence their beliefs about mental health. Based on the information gathered, adiagnosis of schizoaffective disorder has been documented. These symptoms impair the person’s ability to perform daily
activities, maintain social relationships, and hold steady employment. A clinical summary and treatment recommendations werealso documented in the assessment. Next steps include scheduling weekly Individual Therapy sessions with the client andcollaborating with treatment team to determine the most appropriate interventions to assist with addressing the client’s
symptoms of schizoaffective disorder.

Assessment

ASSESSMENT SAMPLE 2

Additional Assessment Tools

Reviewed information gathered from various sources (including x, y, z) to inform the 7 domains of the client’s initial assessmentand established a preliminary diagnosis of Major Depressive Disorder, Recurrent, Severe. Client exhibits and reports symptoms
of depression, suicidal and self-injurious behavior, aggression toward others, and running away. The client's last substance use
occurred a month ago, and there was no current suicidal ideation. The clinician plans to meet with the person in care, family,
and Child and Family Team to update the problem list and formulate a plan for ongoing care.

Diagnosis
Problem List
Care Planning
Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

INDIVIDUAL THERAPY SAMPLE
Checked-in with person in care using scaling question to determine the person's current level of anxiety on a scale from 0-10
with 0 being none and 10 being most ever. Clinician explored what would make person's anxiety rating a point higher and apoint lower. Clinician asked exception-seeking questions to explore times in which person in care has experienced lower ratingsof anxiety and explored what was different about those situations. Clinician asked how they would know if their anxiety wascompletely gone and what would be different. Clinician plans to continue to meet with person in care weekly to work towardachieving person in care's therapy goals which include x, y, z.

INDIVIDUAL REHABILITATION SAMPLEThis writer facilitated mindfulness-based breathing exercise to assist client with strengthening stress management skills, which
directly impacts their experience of depression symptoms. This writer revisited body scan exercise introduced in the previous
rehabilitation session to continue building self-awareness and manage physical symptoms of sadness. To assist with managing
sadness, writer facilitated behavioral activation (outdoors) activity enjoyed by person in care, to build consistency and routine.
Writer encouraged person in care to continue practicing skills to manage symptoms of depression that include sadness until the
Page 99 of 114

next rehabilitation session.

BHRS Documentation
Manual for SMHS
Table of Contents

CASE MANAGEMENT SAMPLEThis staff contacted Group Intervention Center and spoke with intake counselor (Susan) to obtain information about theappropriateness of their Healing Heart Program to meet client’s needs. Staff completed the referral process by summarizing
client’s anxiety symptoms and highlighting strengths, including supportive family members. Healing Hearts indicated client
seemed appropriate for their program group and provided staff with information on next steps. This staff will contact client todiscuss eligibility for program and assist client in preparing to attend this support group.

Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools
Diagnosis
Problem List
Care Planning
Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

Page 100 of 114

APPENDIX ABHRS Documentation
Manual for SMHS
Table of Contents
Introduction

Service Code, Location Code, Time Field Matrix
Entering Time for Reimbursable vs Non-Reimbursable Services.
Billable (Reimbursable)
Service Code55 or 550
Service CodeLockout
Location Code

Missed Visit*
Location Code

Service Time

Use for time spent providing
direct service to thebeneficiary, collateral, orcase management services
with other providers.

Use for time spent
providing the actual
service.

Use for time spent providing
the actual service.

Zero because no service
was provided.

DocumentationTime

Use for time spent on
documentation related towriting the progress note,
assessment, treatment plan,or other clinicaldocumentation.

Use for time spent
documenting note.

Use for time spent on
documentation related towriting the progress note,
assessment, treatment plan,or other clinicaldocumentation.

Use for time spent
documenting note.

Travel Time**

Use for time spent travelingto/from the appointment.**

Use for time spent
traveling to/from theappointment.**

Use for time spent travelingto/from the appointment.**

Use for time spent
traveling to/from theappointment.**

Non-Billable
Time***

Use if a non-billable service
was provided during thisappointment.

N/A

Use if a non-billable service
was provided during thisappointment.

Use if a non-billable
service was provided
during this appointment.

Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools
Diagnosis
Problem List
Care Planning
Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024* When a beneficiary has missed their appointment/visit staff will document this by choosing the service code of the service they had intend
to provide and use the location code Missed Visit. For example, if a beneficiary missed an individual therapy appointment (ex. 30 min),then staff would choose the corresponding CPT code for Individual therapy with the approximated time and choose the location code of
missed visit.
** See the “Documentation and Travel Time” Subsection of “Progress Notes Fields” Section in this manual to learn the amount of time toinclude in “Travel Time”*** Contractors who do not use BHRS Avatar do not have the non-billable time field, so this only applies for those using BHRS Avatar.

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Entering Time for Direct Services vs No Client Present
BHRS Documentation
Manual for SMHS
Table of Contents
Introduction

Individual Services

Group Services

Services Delivered without
Beneficiary Present

Service Time

Entire Time spent providing direct
service.

Entire Time spent providing thegroup service.

Entire Time spent providing direct service.

Documentation
Time

Entire Time spent documenting.

Only the time it took to write thebeneficiary’s note.

Entire Time spent documenting.

Travel Time*

Entire Time spent traveling.*

Entire Time spent traveling for thegroup service.*

Entire Time spent traveling.*

Non-Billable
Time

Entire Time spent providing direct
service.

Only the time it took to provide
unbillable services for thatparticular beneficiary (e.g., timespent completing a mandated
report, etc.).

Entire Time spent providing non-billable
service.

Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools
Diagnosis* See the “Documentation and Travel Time” Subsection of “Progress Notes Fields” Section in this manual to learn the amount of time toinclude in “Travel Time”

Problem List
Care Planning
Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

Page 102 of 114

APPENDIX B
BHRS Documentation
Manual for SMHS

General Definitions of Services

Table of Contents

ADULT RESIDENTIAL TREATMENT SERVICES

Introduction

Documentation Requirements

Adult residential treatment services are recovery focused rehabilitative services,
provided in a non-institutional, residential setting, for beneficiaries who would be atrisk of hospitalization or other institutional placement if they were not in theresidential program.

Access to SMHS and Medical
Necessity

The service is available 24 hours a day, seven days a week. Structured day andevening services are available all seven days.

Screening Tools

Adult residential treatment services must have a clearly established site for services
although all services need not be delivered at that site and some service
components may be delivered through telehealth or telephone. Services will not be
claimable unless the beneficiary has been admitted to the program and there isface-to-face contact between the beneficiary and a staff person of the facility on the
day of service.

Compliance

Assessment
Additional Assessment Tools
Diagnosis

SERVICE COMPONENTS
This service includes one or more of
the following service components:• Assessment• Treatment Planning• Therapy• Psychosocial Rehabilitation

Problem List

ASSESSMENT

Care Planning

Assessment means a service activity designed to collect information and evaluate the current status of a beneficiary’s mental,
emotional, or behavioral health. Assessment includes one or more of the following: mental status determination, analysis of thebeneficiary’s clinical history, analysis of relevant biopsychosocial and cultural issues and history, diagnosis and the use of testingprocedures. Assessments are used to determine whether mental health services are medically necessary and to recommend or
update a course of treatment for that beneficiary.

Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

Page 103 of 114

CRISIS INTERVENTION SERVICES (not crisis stabilization or crisis residential)

BHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools
Diagnosis
Problem List
Care Planning
Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

Crisis Intervention is an unplanned, expedited service, to or on behalf of abeneficiary to address a condition that requires more timely response than aregularly scheduled visit. Crisis intervention is an emergency response service
enabling the beneficiary to cope with a crisis, while assisting the beneficiary inregaining their status as a functioning community member. The goal of crisis
intervention is to stabilize an immediate crisis within a community or clinicaltreatment setting.
Crisis intervention may include contact with significant support persons or othercollaterals if the purpose of their participation is to focus on the treatment of thebeneficiary.

SERVICE COMPONENTS
This service includes one or more of
the following service components:• Assessment•

Collateral•

Therapy

Referral Title 9, CCR, § 1840.366 states that “the maximum amount claimable for Crisis Intervention in a 24-hour period is 8
hours.”CRISIS STABILIZATION – EMERGENCY ROOM
Crisis stabilization is an unplanned, expedited service lasting less than 24 hours, toor on behalf of a beneficiary to address an urgent condition requiring immediate
attention that cannot adequately or safely addressed in a community setting. The
goal of crisis stabilization is to avoid the need for inpatient services which, if thecondition and symptoms are not treated, present an imminent threat to thebeneficiary or others, or substantially increase the risk of the beneficiary becoming
gravely disabled.

SERVICE COMPONENTS
This service includes one or more of
the following service components:•

Assessment• Therapy
Crisis stabilization must be provided on site at a licensed 24-hour health care
• Crisis Intervention
facility, at a hospital-based outpatient program (services in a hospital-based• Medication Support Services
outpatient program are provided in accordance with 42 CFR 440.20), or at a
provider site certified by the Department of Health Care Services to perform crisis• Referral and Linkages
stabilization and some service components may be delivered through telehealth ortelephone. Crisis stabilization may include contact with significant support persons
or other collaterals if the purpose of their participation is to focus on the treatment of the beneficiary.
Medical backup services must be available either on site or by written contract or agreement with general acute care hospital.
Medical backup means immediate access within reasonable proximity to health care for medical emergencies. Medications must
be available on an as needed basis and the staffing pattern must reflect this availability.
All beneficiaries receiving crisis stabilization must receive an assessment of their physical and mental health. This may be
accomplished using protocols approved by a physician. If outside services are needed, a referral that corresponds with thebeneficiary’s needs will be made, to the extent resources are available.
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CRISIS RESIDENTIAL

BHRS Documentation
Manual for SMHS

Crisis Residential Treatment Services (CRTS) are therapeutic or rehabilitative
services provided in a non-institutional residential setting which provides a
structured program (short term-3 months or less) as an alternative tohospitalization for beneficiaries experiencing an acute psychiatric episode or crisis
who do not have medical complications requiring nursing care.

Table of Contents

The service is available 24 hours a day, seven days a week and structured day andevening services are available all seven days.

•

Assessment•

Treatment Planning

Crisis residential treatment services must have a clearly established site forservices although all services need not be delivered at that site and some service
components may be delivered through telehealth or telephone. Services will not
be claimable unless the beneficiary has been admitted to the program and there isface-to-face contact between the beneficiary and a treatment staff person of the
facility on the day of service.

•

Therapy•

Psychosocial Rehabilitation•

Crisis Intervention

Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools
Diagnosis
Problem List
Care Planning
Coordination of Care
Discharges and Transfers
Coding Services

SERVICE COMPONENTS
This service includes one or more of
the following service components:

DAY REHABILITATIONDay Rehabilitation is a structured program which provides services to a distinctgroup of individuals. Day rehabilitation is intended to improve or restore personal
independence and functioning necessary to live in the community or prevent
deterioration of personal independence consistent with the principles of learningand development. Services are available for at least three hours each day.
Day rehabilitation is a program that lasts less than 24 hours each day.
Day rehabilitation may include contact with significant support persons or othercollaterals if the purpose of their participation is to focus on the beneficiary. Day
rehabilitation services must have a clearly established site for services although allservices need not be delivered at that site and some service components may bedelivered through telehealth or telephone.

SERVICE COMPONENTS
This service includes one or more of
the following service components:•

Assessment•

Treatment Planning•

Therapy•

Psychosocial Rehabilitation

Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

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DAY TREATMENT INTENSIVEBHRS Documentation
Manual for SMHS

Day Treatment Intensive is a structured, multi-disciplinary program which provides
services to a distinct group of individuals. Day treatment intensive is intended toprovide an alternative to hospitalization, avoid placement in a more restrictive
setting, or assist the beneficiary in living within a community setting. Services areavailable for at least three hours each day.

Table of Contents

Day treatment intensive is a program that lasts less than 24 hours each day.

Introduction

Day treatment intensive may include contact with significant support persons orother collaterals if the purpose of their participation is to focus on the treatmentof the beneficiary. Day treatment intensive services must have a clearly
established site for services although al services need not be delivered at that siteand some service components may be delivered through telehealth or telephone.

Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools
Diagnosis
Problem List
Care Planning
Coordination of Care
Discharges and Transfers
Coding Services

A – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

This service includes one or more of
the following service components:•

Assessment•

Treatment Planning•

Therapy•

Psychosocial Rehabilitation

INTENSIVE CARE COORDINATION (ICC) SERVICES
ICC is a targeted case management service that facilitates assessment of care planning for, and coordination of services tobeneficiaries under 21 who are eligible for full-scope Medi-Cal services and who meet medical necessity criteria for these
services. ICC service components include assessing, service planning and implementation, monitoring and adapting, andtransition. ICC services are provided through the principles of the Integrated Core Practice Model (ICPM), including theestablishment of the Child and Family Team (CFT) to ensure facilitation of a collaborative relationship among a child, theirfamily, and involved child-serving systems. Intensive Care Coordination (ICC) Child Family Team Meeting (CFT). ICC is a specialty
mental health service covered as Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services.
The CFT is comprised of, as appropriate, both formal supports, such as the care coordinator, providers, case managers fromchild-serving agencies, and natural supports, such as family members, neighbors, friends and clergy and all ancillary beneficiaries
who work together to develop and implement the beneficiary plan and are responsible for supporting the child and family inattaining their goals. CFTs are supported by an ICC coordinator who:•

Ensures that medically necessary services are accessed, coordinated and delivered in a strength-based, individualized,
family/child driven and culturally and linguistically competent manner and that services and supports are guided by theneeds of the child;•

Facilitates a collaborative relationship among the child, their family and systems involved in providing services to thechild;•

Supports the parent/caregiver in meeting their child’s needs;•

Helps establish the CFT and provides ongoing support; and•Organizes and matches care across providers and child serving systems to allow the child to be served in the community.

Progress Notes
Appendices

SERVICE COMPONENTS

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INTENSIVE HOME BASED SERVICES (IHBS)BHRS Documentation
Manual for SMHS
Table of Contents

IHBS are individualized, strength-based interventions designed to correct or ameliorate mental health conditions that interferewith a child or youth’s functioning and are aimed at helping the child or youth build skills necessary for successful functioning in
the home and community, and improving the child’s or youth’s family’s ability to help the child or youth successfully function in
the home and community. IHBS services are provided according to an individualized treatment plan developed in accordancewith the Integrated Core Practice Model (ICPM) by the Child and Family Team (CFT) in coordination with the family’s overall
service plan.

Introduction•

IHBS may include but are not limited to assessment, plan development, therapy, rehabilitation and collateral.

Compliance•

IHBS is provided to beneficiaries under 21 who are eligible for full-scope Medi-Cal services and who meet medical
necessity criteria.

Documentation Requirements
Access to SMHS and Medical
Necessity

PLAN DEVELOPMENT

Screening Tools

Plan Development means a service activity that consists of one or more of the following: developing or updating a beneficiary’s
course of treatment, documentation of the recommended course of treatment, and monitoring of a beneficiary’s progress.

Assessment

MEDICATION SUPPORT SERVICES

Additional Assessment Tools

Medication Support Services include one or more of the following:prescribing, administering, dispensing and monitoring druginteractions and contraindications of psychiatric medications or
biologicals that are necessary to alleviate the suffering andsymptoms of mental illness. Medication Support Services areindividually tailored to address the beneficiary’s need and areprovided by a consistent provider who has an establishedrelationship with the beneficiary.

Diagnosis
Problem List
Care Planning
Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions

Medication support services may include contact with significant
support persons or other collaterals if the purpose of their
participation is to focus on the treatment of the beneficiary.
Medication support services may be delivered as a standalone
service or as a component of crisis stabilization.
Title 9, CCR, § 1840.372 states that “the maximum amountclaimable for Medication Support Services in a 24-hour period is 4
hours.”SERVICE COMPONENTS
This service includes one or more of the following
service components:•

Evaluation of the need for medication•

Evaluation of clinical effectiveness and side
effects•

The obtaining of informed consent•

Medication education including instructionin the use, risks, possible side effects, andbenefits of and alternatives for medication•

Collateral•

Plan Development

C – Progress Note Templates
Last Updated: 10/17/2024

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MOBILE CRISES RESPONSE TEAMBHRS Documentation
Manual for SMHS

The mobile crises services benefit is part of the transformation of Medi-Cal reform. The intention is to help bridge the gap in thefollowing areas of concern for DHCS:•

Many California’s facing mental health or substance use crises often end up dealing with the wrong systems like law
enforcement or hospital emergency rooms, without getting the help they need.

Table of Contents•

In 2020, one out of every five people visiting emergency departments had a mental health or substance use issue.

Introduction•

Mobile crises services re there to help anyone going through a mental health or substance use crises services in thecommunity, around the clock (24/7).

•

Research shows that these services can effectively handle crises in the community, steer people away frominappropriate systems, and connect them with the right ongoing support.

Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools
Diagnosis

In San Mateo County, BHRS has selected Telecare Corp to provide the mobile crises response team services and will work with
StarVista as the current provider of our Crises Line. Callers can request mobile crisis services by calling (650) 573-0350 and thespecialist teams will be deployed to provide crises services to San Mateo County residents.
This specialist service has specific documentation requirements. Within our EHR, there is a unique progress note that willcapture the following requirements:•

Category of the Note:o Crises Evaluationo Initial Follow-up
o Additional Follow-up

Problem List
Care Planning
Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024•

Service Start Time & Service End Time (Service Duration)•

Location -Where was the service provided, i.e.-street, home, shelter, school.

•

Crises Category/Nature of Call -Domestic Violence, Gravely Disabled, Homicidal Ideation, Suicidal Ideation, Other.

•

Crises Call Request Time•

Response Method (In-person/Not In-person)- If not in person, provide reason.
•
•
•
•
•

Arrival Time
Travel Time
Follow-up Details
Notes Field
Final/Draft
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PEER SUPPORT SERVICESBHRS Documentation
Manual for SMHS
Table of Contents

Peer Support Services are culturally competent beneficiary and group services that promote recovery, resiliency, engagement,socialization, self-sufficiency, self-advocacy, development of natural supports, and identification of strengths through structured
activities such as group and beneficiary coaching to set recovery goals and identify steps to reach the goals.
Services aim to prevent relapse, empower beneficiaries through strength-based coaching, support linkages to community
resources, and to educate beneficiaries and their families about their conditions and the process of recovery.

Compliance

Peer support services may be provided with the beneficiary or significant support person(s) and may be provided in a clinical or
non-clinical setting. Peer support services can include contact with family members or other collaterals if the purpose of thecollateral’s participation is to focus on the treatment needs of the beneficiary by supporting the achievement of thebeneficiary’s treatment goals.

Documentation Requirements

Peer support may be provided as a group service or a one-on-one service.

Introduction

Access to SMHS and Medical
Necessity•

Educational Skill Building Groups means providing a supportive environment in which beneficiaries and their families
learn coping mechanisms and problem-solving skills in order to help the beneficiaries achieve desired outcomes. These
groups promote skill building for the beneficiaries in the areas of socialization, recovery, self-sufficiency, self-advocacy,development of natural supports, and maintenance of skills learned in other support services.

•

Engagement means Peer Support Specialist led activities and coaching to encourage and support beneficiaries toparticipate in behavioral health treatment. Engagement may include supporting beneficiaries in their transitions andsupporting beneficiaries in developing their own recovery goals and processes.

•

Therapeutic Activity means a structured non-clinical activity provided by a Peer Support Specialist to promote recovery,
wellness, self-advocacy, relationship enhancement, development of natural supports, self-awareness and values, andthe maintenance of community living skills to support the beneficiary’s treatment to attain and maintain recovery within
their communities. These activities may include, but are not limited to, advocacy on behalf of the beneficiary; promotionof self-advocacy; resource navigation; and collaboration with the beneficiaries and others providing care or support tothe beneficiary, family members or significant support persons.

Screening Tools
Assessment
Additional Assessment Tools
Diagnosis
Problem List
Care Planning
Coordination of Care
Discharges and Transfers
Coding Services

PEER SUPPORT SPECIALISTS

Progress Notes

Peer support services are provided by certified Medi-Cal Peer Support Specialists. Certified Medi-Cal Peer Support Specialists are
beneficiaries 18 years of age or older who self-identify as having lived experience with the process of recovery from mental
illness, substance use disorder or both, either as a consumer of behavioral health treatment services or as a parent or family
member of a consumer, and who have a current Peer Support Specialist certification in California. The Peer Support Specialist
serves as part of an integrated and/or multidisciplinary treatment team and offers an invaluable perspective on the mosteffective.

AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

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REHABILITATIONBHRS Documentation
Manual for SMHS

Rehabilitation means a recovery or resiliency-focused service activity identified to address a mental health need in the problem
list. This service activity provides assistance in restoring, improving, and/or preserving a beneficiary’s functional, social,communication, or daily living skills to enhance self-sufficiency or self-regulation in multiple life domains relevant to thedevelopmental age and needs of the beneficiary. Rehabilitation also includes support resources, and/or medication education.

Table of Contents

Rehabilitation includes therapeutic interventions that utilize self-expression such as art, recreation, dance or music as a modality
to develop or enhance skills. These interventions assist the beneficiary in attaining or restoring skills which enhance community
functioning including problem solving, organization of thoughts and materials, and verbalization of ideas and feelings.

Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools
Diagnosis
Problem List
Care Planning

Rehabilitation may be provided to a beneficiary or a group of beneficiaries. For example, rehabilitation also includes assisting
beneficiaries to develop coaching skills by using a group process to provide peer interaction and feedback in developing
problem-solving strategies.

THERAPY (includes beneficiary therapy, group therapy, family therapy)
Therapy means a service activity that is a therapeutic intervention that focuses primarily on symptom reduction and restorationof functioning as a means to improve coping and adaptation and reduce functional impairments. Therapeutic intervention
includes the application of cognitive, affective, verbal or nonverbal strategies based on the principles of development, wellness,
adjustment to impairment, recovery and resiliency to assist a beneficiary in acquiring greater personal, interpersonal andcommunity functioning or to modify feelings, thought processes, conditions, attitudes or behaviors which are emotionally,
intellectually, or socially ineffective. These interventions and techniques are specifically implemented in the context of aprofessional clinical relationship.
Therapy may be delivered to a beneficiary or group of beneficiaries and may include family therapy directed at improving thebeneficiary’s functioning and at which the beneficiary is present.

Coordination of Care

TARGETED CASE MANAGEMENT (CASE MANAGEMENT/BROKERAGE/LINKAGE)

Discharges and Transfers

Progress Notes

Services that assist a person in care to access needed medical, educational, social, prevocational, vocational, rehabilitative, orother community services. The service activities may include, but are not limited to, communication, coordination, and referral;monitoring service delivery to ensure access to service and the service delivery system; monitoring of beneficiary progress;
placement services and plan management. TCM services may be with the beneficiary or significant support persons.

Appendices

THERAPEUTIC BEHAVIORAL SERVICES (TBS)

Coding Services

A – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

Specialty mental health services covered as Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services. TBS areintensive, one-to-one, short-term outpatient services for beneficiaries up to age 21 designed to help beneficiaries and theirparents/caregivers manage specific behaviors using short term measurable goals based on the beneficiary’s needs. Beneficiaries
receiving these services have serious emotional disturbances (SED), are experiencing a stressful transition or life crisis and needadditional short-term, specific support services to accomplish specified outcomes.
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THERAPEUTIC FOSTER CARE (TFC) SERVICESBHRS Documentation
Manual for SMHS

This model allows for the provision of short term, intensive, highly coordinated, trauma informed and individualized specialty
mental health services (SMHS) activities (plan development, rehabilitation and collateral) to children and youth up to age 21
who have complex emotional and behavioral needs and who are placed with trained, intensely supervised and supported TFC
parents. The TFC parent serves as a key participant in the therapeutic treatment process of the child or youth.

Table of Contents

TFC is intended for children and youth who require intensive and frequent mental health support in a family environment. The
TFC service model allows for the provision of certain SMHS activities (plan development, rehabilitation and collateral) available
under the EPSDT benefit as a home-based alternative to high level care in institutional settings such as group homes and analternative to Short Term Residential Therapeutic Programs (STRTPs).

Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools
Diagnosis
Problem List
Care Planning
Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix

Special Note about Collateral Services
Under CalAIM, the way that a collateral service is billed has changed. Instead of a collateral service being its own distinct
service code, the way it was previously, Collateral instead is viewed as a component of many different services. A provider
working with the beneficiary’s support person would select the service code that most accurately represents the service
they are providing and indicate on the progress note that this service was provided to the collateral contact. Here are a few
examples:Sample Collateral Scenario

Service Code

Meeting with the beneficiary’s caregiver/significant support person to gather assessment
information.

Assessment

Meeting with the beneficiary’s caregiver/significant support person to develop a plan fortreatment.

Plan
Development

Meeting with the beneficiary’s caregiver/significant support person for the purpose ofcoaching, skill development as way to support the beneficiary with managing behavioral healthneeds.

Rehabilitation

Meeting with the beneficiary’s caregiver/significant support person for the purpose ofconnecting them with resources/community supports to address the beneficiary’s needs.

CaseManagement

B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

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APPENDIX CBHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment

Progress Note Templates
Services Provided to an Individual (Not Group) Template
IN-PERSON SERVICE (NOT GROUP)
List people involved in the services and their role:
Service: Include how the service addressed the client's behavioral health needs (e.g., activities or interventions used, any issues
discussed, progress toward goals).
Plan: Summary of plan or next steps (e.g., action steps, collaboration with client or providers, goals, steps to address client's
needs, updates to problem list and/or treatment plan, referral, discharge planning).
Next Appointment: (Include earliest offered appointment date for next appointment).

Additional Assessment Tools
Diagnosis
Problem List
Care Planning
Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

REMOTE SERVICE (NOT GROUP)
List people involved in the services and their role:
Location of the client at the time of service:
Service: Include how the service addressed the client's behavioral health needs (e.g., activities or interventions used, any issues
discussed, progress toward goals).
Plan: Summary of plan or next steps (e.g., action steps, collaboration with client or providers, goals, steps to address client's
needs, updates to problem list and/or treatment plan, referral, discharge planning).
Next Appointment: (Include earliest offered appointment date for next appointment).

Group Services Template
IN-PERSON SERVICE (GROUP)
ONLY COMPLETE THE FOLLOWING PROMPT FOR GROUPS WITH MORE THAN 1 FACILITATOR: Describe YOUR (1) specificinvolvement in the group and (2) The specific amount of time of YOUR involvement in the group activity.
Service: Include how the service addressed the client's behavioral health needs (e.g., activities or interventions used, any issues
Page 112 of 114

discussed, progress toward goals).

BHRS Documentation
Manual for SMHS

Response: Describe the client's response to the service (e.g., effectiveness of the intervention, progress or barriers, other info
relevant to member's participation).
Plan: Summary of plan or next steps (e.g., action steps, collaboration with client or providers, goals, steps to address client's
needs, updates to problem list and/or treatment plan, referral, discharge planning).

Table of Contents

Next Appointment: (Include earliest offered appointment date for next appointment).

Introduction

REMOTE (GROUP)

Compliance

ONLY COMPLETE THE FOLLOWING PROMPT FOR GROUPS WITH MORE THAN 1 FACILITATOR: Describe YOUR (1) specificinvolvement in the group and (2) The specific amount of time of YOUR involvement in the group activity.

Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools

Location of the client at the time of service:
Service: Include how the service addressed the client's behavioral health needs (e.g., activities or interventions used, any issues
discussed, progress toward goals).
Response: Describe the client's response to the service (e.g., effectiveness of the intervention, progress or barriers, other info
relevant to member's participation).

Diagnosis

Plan: Summary of plan or next steps (e.g., action steps, collaboration with client or providers, goals, steps to address client's
needs, updates to problem list and/or treatment plan, referral, discharge planning).

Problem List

Next Appointment: (Include earliest offered appointment date for next appointment).

Care Planning

Crisis Intervention Services Template

Coordination of Care
Discharges and Transfers
Coding Services
Progress Notes
Appendices

CRISIS INTERVENTIONONLY FOR REMOTE CRISIS SERVICE: Location of the client at the time of service:
List people involved in the services and their role:
Service: Include how the service addressed the client's behavioral health needs (e.g., activities or interventions used, any issues
discussed, progress toward goals).

A – Service Code, Location
Code, Time Field Matrix

Plan: Summary of plan or next steps (e.g., action steps, collaboration with client or providers, goals, steps to address client's
needs, updates to problem list and/or treatment plan, referral, discharge planning).

B – Service Definitions

Specific Safety Plan (if needed):C – Progress Note Templates

Next Appointment: (Include earliest offered appointment date for next appointment).

Last Updated: 10/17/2024

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Medication Support Template
BHRS Documentation
Manual for SMHS
Table of Contents
Introduction
Compliance
Documentation Requirements
Access to SMHS and Medical
Necessity
Screening Tools
Assessment
Additional Assessment Tools
Diagnosis
Problem List
Care Planning

MEDICATION SUPPORT Interval History
 Mental Status Examination
 General Appearance /Behavior
 Speech Mood /Affect Perceptions /Thought Content /Thought Process Attention /Concentration
 Orientation /Cognition /Memory Judgment: Insight: Risk Assessment
 Med Assessment: Comment Diagnosis:
 PlanCoordination of Care
Discharges and Transfers
Coding Services
Progress Notes
AppendicesA – Service Code, Location
Code, Time Field Matrix
B – Service Definitions
C – Progress Note Templates
Last Updated: 10/17/2024

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