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Medical Doctor (MD) & Doctor of Osteopathy (DO)

Service AreaProcedure Name Displayed in EHRProcedure Definition (Developed by CalMHSA)
MHAssessment Contribution non-LPHAUsed to document assessment work/services completed by non-clinical staff. Assessment means a service activity designed to 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 the beneficiary’s clinical history, analysis of relevant biopsychosocial and cultural issues and history, diagnosis and the use of testing procedures. 15 minutes
MH, DMC, DMC-ODSAssessment LPHAPsychiatric diagnostic evaluation is an integrated biopsychosocial assessment, including history, mental status, and recommendations. Although physicians and other qualified medical staff are permitted to utilize this code, this procedure code is mainly utilized by non-physician clinical staff who are documenting services that would typically fall under the category of "Assessment". 15 minutes
MH, DMC, DMC-ODSAssessment MDThis procedure code is mainly utilized by physicians and other qualified healthcare providers to document "Psychiatric Evaluation" services, including determination of a diagnosis. Psychiatric diagnostic evaluation with medical services is an integrated biopsychosocial and medical assessment, including history, mental status, other physical examination elements as indicated, and recommendations. The evaluation may include communication with family or other sources, prescription of medications, and review and ordering of laboratory or other diagnostic studies. 15 minutes
MH, DMC, DMC-ODSCare Coordination Outside System of Care

For SMHS: This service is designated by HCPCS code H2021 and refers to coordination of care between providers in the Mental Health System and providers who are outside the Mental Health system. H2021 can only be used
to show that a delivery-system coordination of care has occurred. For other kinds of coordination, other service codes must be used. Per 15 minutes.

For DMC & DMC-ODS: This service is designated by HCPCS code H2021 and refersto coordination of care between providers in the Drug Medi-Cal System and providers who are outside the Drug medi-Cal System. H2021 can only be used to show that a delivery-system coordination of care has occurred. For other kinds of coordination, other service codes must be used. Per 15 minutes.

MHCare Management Services for Behavioral Health Conditions by Physician

Care management services for behavioral health conditions, at least 20 minutes of clinical staff time, directed by a physician or other qualified health care professional, per calendar month, with the following required elements:
*Initial assessment or follow-up monitoring, including the use of applicable validated rating scales,
*Behavioral health care planning in relation to behavioral/psychiatric health problems, including revision for patients who are not progressing or whose status changes,
*Facilitating and coordinating treatment such as psychotherapy, pharmacotherapy, counseling and/or psychiatric consultation, and
*Continuity of care with a designated member of the care team.

MHConsults for New and Established Patients'99242: The provider sees a patient for an office or other outpatient consultation involving evaluation and management (E/M). Straightforward medical decision making or at least 21 minutes of total time. 99243: The provider sees a patient for an office or other outpatient consultation involving evaluation and management (E/M). Low level of medical decision making or at least 30 minutes of total time. 99244: The provider sees a patient for an office or other outpatient consultation involving evaluation and management (E/M). Moderate level of medical decision making or at least 40 minutes of total time. 99245: The provider sees a patient for an office or other outpatient consultation involving evaluation and management (E/M). High level of medical decision making or at least 55 minutes of total time.
MH, DMC, DMC-ODSCrisis Intervention/Mobile CrisisA service, lasting less than 24 hours, to or on behalf of a beneficiary for a condition that requires more timely response than a regularly scheduled visit. Service activities include but are not limited to one or more of the following: assessment, collateral and therapy. Clinical providers who are providing crisis intervention should consider whether Psychotherapy for Crisis would be a more appropriate code for the service rendered. Per 15 minutes
MH, DMC-ODSFamily Therapy - client present"Family Therapy" services for the purposes of improving the beneficiary's functioning. The patient must be present for this service. Therapy may be delivered to a beneficiary or group of beneficiaries and may include family therapy directed at improving the beneficiary’s functioning and at which the beneficiary is present. 26-50 minutes
MHGroup TherapyDocuments provision of "typical" group therapy services that include multiple beneficiaries. Therapy may be delivered to a beneficiary or group of beneficiaries and may include family therapy directed at improving the beneficiary’s functioning and at which the beneficiary is present. 15 minutes
MH, DMC-ODSHome Visit of a New Patient'Evaluation & Management service of new patient provided in the individual's home. Procedures should be selected based on direct service time. "New Patient" = The individual has not received any professional services within the last three years from the physician, or another physician of the same specialty who belongs to the same group practice. 99341: 15-25 minutes, 99342: 26-35 minutes, 99343: 36-50 minutes, 99344: 51-65 minutes, 99345: 66-80 minutes
MH, DMC-ODSHome Visit of an Established Patient'Evaluation & Management service of new patient provided in the individual's home. Each CPT code includes an associated time. "Established Patient" = The individual has received professional services within the last three years from the physician, or another physician of the same specialty who belongs to the same group practice. 99347: 10-20 minutes, 99348: 21-35 minutes, 99349: 36-50 minutes, 99350: 51-70 minutes
MHIndividual Therapy'"Individual Therapy" services provided to a beneficiary focused primarily on symptom reduction and restoration of 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 and community functioning or to modify feelings, thought processes, conditions, attitudes or behaviors which are emotionally, intellectually, or socially ineffective. Each Psychotherapy with Patient CPT represents a specific length of time: 90832: 30 minutes, 90834: 45 minutes and 90837: 60 minutes. The beneficiary must be present for these services.
MH, DMC-ODSMedical Team Conference,Participation by Physician. Pt and/or Family Not PrMedical team conference with interdisciplinary team of health care professionals, patient and/or family not present, 30 minutes or more; participation by physician.
MHMedication InjectionUtilized to document psychiatric medication intramuscular and subcutaneous injections. 15 minutes
MH, DMC, DMC-ODSMedication Support Existing Client

'Used to document evaluation and management medications upport services provided to established patients who have had a visit in the last 3 years. "Established Patient" = The individual has received professional services within the last three years from the physician, or another physician of the same specialty who belongs to the same group practice. 99212: 10-19 minutes, 99213: 20-29 minutes, 99214: 30-39 minutes, 99215: 40-54 minutes
*These codes use the same psych note template and so previous data will be saved from the last note.

MH, DMC, DMC-ODSMedication Support New Client

'Used to document evaluation and management medication support services provided to new patients where it has been greater than 3 years since their last visit. "New Patient" = The individual has not received any professional services within the last three years from the physician, or another physician of the same specialty who belongs to the same group practice. 99202: 15-29 minutes, 99203: 30-44 minutes, 99204: 45-59 minutes, 99205: 60-74 minutes
*These codes use the same psych note template and so previous data will be saved from the last note.

MH, DMC, DMC-ODSMedication Support Telephone

'Evaluation & Management services provided by telephone.
99441: 5-10 minutes,
99442: 11-20 minutes
99443: 21-30 minutes

MH, DMC, DMC-ODSMedication Training and SupportMedication education, training and support, monitoring/discussing/reviewing side effects. Per 15 minutes.
MH, DMC, DMC-ODS

MH- Care Coordination with non-MHP provider

DMC - Care Coordination with non-DMC provider

For SMHS: This service is designated by HCPCS code H2021 and refers to coordination of care between providers in the Mental Health System and providers who are outside the Mental Health system. H2021 can only be used
to show that a delivery-system coordination of care has occurred. For other kinds of coordination, other service codes must be used. Per 15 minutes.

For DMC & DMC-ODS: This service is designated by HCPCS code H2021 and refersto coordination of care between providers in the Drug Medi-Cal System and providers who are outside the Drug medi-Cal System. H2021 can only be used to show that a delivery-system coordination of care has occurred. For other kinds of coordination, other service codes must be used. Per 15 minutes.

MH, DMC-ODSMultiple-Family Group PsychotherapyA group therapy code that allows for documentation of groups that include multiple families vs. a single family. Therapy may be delivered to a beneficiary or group of beneficiaries and may include family therapy directed at improving the beneficiary’s functioning and at which the beneficiary is present. 15 minutes
MH, DMC, DMC-ODSOral Medication AdministrationAdministration of oral medication with direct observation. 15 minutes. This code is also used by LVNs/LPTs and Pharmacists to document the administration of injectable medications.
MH, DMC-ODSPhysician ConsultationUtilized to document time spent by a consulting physician to access data/information via an EHR, telephone, internet, performing data review and/or analysis and concludes with completing a written report. 5-15 minutes.
MHPlan Development, non-physicianPlan Development means a service activity that consists of one or more of the following: development of client plans, approval of client plans and/or monitoring of a beneficiary’s progress. Physicians do not utilize this HCPCS code as Medication Support Services include plan development as a component of those services. 15 minutes
MH, DMC, DMC-ODSPsychological TestingAdministration, review, explanation of psychological testing instruments/tools. First hour.
MH, DMC-ODSPsychosocial Rehab - Individual

For SMHS, "Rehabilitation” means a service activity which includes, but is not limited to assistance in improving, maintaining, or restoring a beneficiary’s or group of beneficiaries’ functional skills, daily living skills, social and leisure skills, grooming and personal hygiene skills, meal preparation skills, and support resources; and/or medication education. Per 15 minutes.

For DMC-ODS, rehabilitation falls under Recovery Services and can document education related to mental health, substance abuse, independent living, social, coping and interpersonal skills, relapse prevention, etc. Per 15 minutes.

MH, DMC-ODSPsychosocial Rehabilitation Group

For SMHS, "Rehabilitation” means a service activity which includes, but is not limited to assistance in improving, maintaining, or restoring a beneficiary’s or group of beneficiaries’ functional skills, daily living skills, social and leisure skills, grooming and personal hygiene skills, meal preparation skills, and support resources; and/or medication education.

For DMC-ODS, rehabilitation falls under Recovery Services and can document education related to mental health, substance abuse, independent living, social, coping and interpersonal skills, relapse prevention, etc.

MHPsychotherapy for CrisisThe individual must be present for all or part of the service. Urgent assessment and exploration of an individual in crisis. Includes mental status exam as well as a disposition and treatment includes therapy, mobilization of resources and implementation of interventions to address the crisis. 30-74 minutes
MHPsychotherapy with Patient with an EM Service'Utilized to document when psychotherapy services were provided as part of an evaluation and management service.
MH, DMC, DMC-ODSReview of Hospital RecordsReview of records for psychiatric evaluation without direct patient contact. This may be accomplished at the request of an agency or peer review organization. 15 minutes
MHTCM/ICCServices that assist a beneficiary to access needed medical, educational, social, prevocational, vocational, rehabilitative, or other community services. The service activities may include, but are not limited to, communication, coordination, and referral; monitoring service delivery to ensure beneficiary access to service and the service delivery system; monitoring of the beneficiary’s progress; placement services; and plan development. Each 15 minutes. This is also the code utilized to capture Intensive Care Coordination (ICC) services.
MH, DMC-ODSTeam Case Conference with Client/Family absentDocuments medical team conference with interdisciplinary team, participation by non-physician. Patient and/or family not present. 30 minutes or more
MH Team Case Conference with Client/Family presentDocuments medical team conference with interdisciplinary team, participation by a non-physician. Face to face with patient and/or family present. 30 minutes or more