|Procedure Name Displayed in EHR
|Procedure Definition (Developed by CalMHSA)
|Assessment Contribution non-LPHA
|Used 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-ODS
|Psychiatric 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-ODS
|Care 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
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.
|Care 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.
|MH, DMC, DMC-ODS
|Crisis Intervention/Mobile Crisis
|A 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
|Family 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
|Documents 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
|'"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, DMC-ODS
|Oral Medication Administration
|Administration 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.
|Multiple-Family Group Psychotherapy
|A 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
|Plan Development, non-physician
|Plan 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-ODS
|Administration, review, explanation of psychological testing instruments/tools. First hour.
|Psychosocial 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.
|Psychosocial 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.
|Psychotherapy for Crisis
|The 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
|MH, DMC, DMC-ODS
|Review of Hospital Records
|Review 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
|Therapeutic Behavioral Services (TBS) is an adjunctive program that supports other services patients are currently receiving. TBS is an intensive, individualized, one-to-one behavioral health service available to children/youth with serious emotional challenges and their families, who are under 21 years old and have full-scope Medi-Cal. Per 15 minutes.
|Services 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.
|Team Case Conference with Client/Family absent
|Documents medical team conference with interdisciplinary team, participation by non-physician. Patient and/or family not present. 30 minutes or more
|Team Case Conference with Client/Family present
|Documents medical team conference with interdisciplinary team, participation by a non-physician. Face to face with patient and/or family present. 30 minutes or more