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Registered Nurse Clinical Trainee (RN Trainee)

DMC State Plan DMC-ODS MH Procedure Name Displayed in EHR Procedure Definition (Developed by CalMHSA)
N Y N Health Risk Assessment Administration and review/interpretation of findings related to health risk assessments.
Y Y N SUD Screening Screening to determine the appropriate services for an individual seeking treatment.
Y Y N Alcohol and/or drug screening Used to document administration/review of alcohol and/or drug screening.
Y Y N Alcohol and/or drug screening. Laboratory analysis Laboratory results review/interpretation/analysis related to an alcohol and/or drug screening.
N Y N Contingency Management This procedure must be used to submit claims for Contingency Management Services. 15 minutes
Y Y N SUD Crisis Intervention SUD Crisis Intervention Services consist of contacts with a beneficiary in crisis. A crisis means an actual relapse or an unforeseen event or circumstance, which presents to the beneficiary an imminent threat of relapse.�These services should focus on alleviating the crisis problem, be limited to the stabilization of the beneficiary�s immediate situation and be provided in the least intensive level of care that is medically necessary to treat their condition.
Y Y N Group Counseling Group counseling related to alcohol and/or drug services. 15 minutes
N Y N Acute Detox (hospital inpatient) This code falls under "Recovery Services". Used to document acute detoxification-related services in an inpatient hospital setting.
N Y N Sub-acute detox (hospital inpatient) This code falls under "Recovery Services". Used to document subacute detoxification-related services in an inpatient hospital setting.
Y Y N Lab Specimen Collection Used to document administration of alcohol and/or other drug testing when collecting and handling specimens other than blood.
N Y N AOD Treatment This code falls under "Recovery Services". Used to document alcohol and/or other drug treatment program services. Per hour
Y Y N ASAM or other structured SUD Assessment Documents determination of ASAM criteria and each code is for a different amount of time: G2011: 5-14 minutes G0396: 15-30 minutes G0397: 30+ minutes Can also be used for other structured SUD assessments.
Y Y N Family/Couple Counseling Alcohol and/or substance abuse services provided with a family/couple.
Y Y N Discharge Planning Utilized when developing discharge summaries and/or discharge plans and reviewing these documents with the beneficiary.
N N Y Application of On-body Injector for Timed Subcutaneous Injection Application of on-body injector (includes cannula insertion) for timed subcutaneous injection. 15 minutes
Y Y N Individual Counseling Individual Counseling consists of contacts with a beneficiary. Individual counseling can include contact with family members or other collaterals if the purpose of the collateral�s participation is to focus on the treatment needs of the beneficiary by supporting the achievement of the beneficiary's treatment goals. 15 minutes
N N Y Brief Emotional/Behavioral Assessment Brief emotional/behavioral assessment (e.g., depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument. 15 minutes
N N Y Caregiver Assessment Administration of Care-Giver Risk Assessmt Administration of caregiver-focused health risk assessment instrument (e.g., depression inventory) for the benefit of the patient, with scoring and documentation, per standardized instrument. 15 minutes
Y Y Y 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 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.
Y Y N Comprehensive Community Supports Services related to helping patients access needed medical, social, educational, and other health-related services. Per 15 minutes. For DMC-ODS this is a "Recovery Service" and for DMC this is a "Treatment Planning" service.
N N Y Comprehensive Multidisciplinary Evaluation Services related to the completion of a multidisciplinary evaluation (i.e. an evaluation that is administered and informed by professionals from various areas of expertise). 15 minutes
Y N Y Crisis Intervention 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
N N Y Developmental Screening Developmental screening (e.g., developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument. 15 minutes
N Y N Environmental intervention for medical mgmt purposes on a psych patient's b Working with agencies, employers, or institutions to address a patient's physical environment as a means to address psychiatric needs/care.
Y Y N Health Behavior Intervention - with Family Includes supporting improvements in function, minimizing psychological and/or psychosocial barriers to recovery, and improved coping skills related to medical conditions. Patient is not present. 16-30 minutes
N N Y Intravenous Infusion, for Therapy, Prophylaxis, or Diagnosis Utilized to document Intravenous infusion, for therapy, prophylaxis or diagnosis (specify substance or drug), initial, 1-60 minutes
N N Y 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
N Y Y 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
Y Y Y Medication Training and Support Medication education, training and support, monitoring/discussing/reviewing side effects. Per 15 minutes.
N N Y 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
N N Y 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
N N Y Neurobehavioral Status Exam Neurobehavioral status exams include assessment of thinking, reasoning and judgement, e.g., acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities). Includes both face-to-face time as well as time interpreting test results and preparing reports. First hour
N N Y Nursing Evaluation Documents the provision of services related to a nursing assessment/evaluation. Includes, but is not limited to, assessment of current physical and psychological needs, analysis of history/medical history, diagnosis, vitals, mental status exam, etc. 15 minutes
Y Y Y 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.
N Y N Prenatal Risk Assessment Administration of risk assessment related to prenatal care.
N Y N Report Generation for Care Coordination Utilized to document preparing reports for other individuals, agencies, etc. for the purposes of care coordination.
Y Y N Psychoeducation Includes providing information regarding mental illness and substance abuse and teaches problem-solving, communication, and coping skills to support recovery and resilience. Per 15 minutes
N Y Y 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.
Y Y N Client Education The DHCS billing manual states that this should be utilized to submit claims for Patient Education Services. Per 15 minutes
N N Y Subcutaneous Infusion for Therapy or Prophylaxis, Initial Documents setting up of infusion pump, establishing a subcutaneous port site, and infusing a medication via the pump for a period up to one hour for prevention or therapeutic purposes. 15-60 minutes
N Y Y TCM/ICC 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. Targeted Case Management is a type of Care Coordination code that can be used by DMC-ODS providers.
N N Y TBS 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.
N N Y Therapeutic, Prophylactic, or Diag Injection; Single or Initial Substance/D Intravenous push, single or initial substance/drug. 15 minutes
N N Y Medication Injection Utilized to document psychiatric medication intramuscular and subcutaneous injections. 15 minutes
N N Y Therapeutic, Prophylactic, or Diagnostic Injection; Intra-Arterial Utilized to document intra-arterial injections. 15 minutes
N N Y Psychiatric Inpatient Day - Adult Utilized to document general inpatient psychiatric services provided to individuals 21 through 64.
N N Y Psychiatric Inpatient Day - Youth Utilized to document general inpatient psychiatric services provided to individuals under 21 years of age.
Y Y N Methadone - Day Service Methadone administration and/or service (provision of the drug by a licensed program)
N N Y Psychiatric Inpatient Day - Older Adult Utilized to document general inpatient psychiatric services provided to individuals age 65 and older.
N N Y General Inpatient - Admin Day Documentation of administrative days during a general inpatient hospitalization.
N N Y Psychiatric Hospital Inpatient Admin Day Documentation of administrative days during a psychiatric inpatient hospitalization.
N N Y Psychiatric Health Facility Day Inclusive of services provided within a psychiatric health facility (PHF)
N N Y Therapeutic Foster Care Short-term, intensive, highly coordinated, trauma informed and individualized 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. 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 an alternative to Short Term Residential Therapeutic Programs (STRTPs
Y N Y Crisis Residential Day - Older Adult Children�s-Adult Crisis Residential: Geriatric services.
Y N Y Crisis Residential Day - Adult Children�s-Adult Crisis Residential: Non-Geriatric services.
N N Y Crisis Residential Day - Youth Children�s-Adult Crisis Residential services.
N N Y Adult Residential Day - Older Adult Adult Residential: Geriatric services.
N N Y Adult Residential Day Adult Residential: Non-Geriatric services.
N N Y Crisis Stabilization - Emergency Room Services Crisis Stabilization: Emergency Room services.
N N Y Crisis Stabilization Unit Crisis Stabilization: Urgent Care services.
N N Y Day Treatment Intensive - Half Day Half Day of Day Treatment Intensive services.
N N Y Day Treatment Intensive - Full Day Full Day of Day Treatment Intensive services.
N N Y Day Rehabilitation - Half Day Half Day of Day Rehabilitation services.
N N Y Day Rehabilitation - Full Day Full Day of Day Rehabilitation services.
N Y Y 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.
Y Y Y Care Coordination Outside System of Care Group 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 refers to 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.
Y Y N Residential Treatment -Substance Use H0012: Alcohol and/or drug services: (residential addiction program outpatient). Subacute detoxification (DMC-ODS ONLY) H0019: Behavioral Health; Long Term Residential (non-medical, non-acute care in a residential treatment program where stay is typically longer than 30 days) without room and board (Both DMC and DMC-ODS)
- - - General Outreach An outreach activity not tied to a specific client. For example: running a mental health/behavioral health booth at a local fair. This would be used in conjunction with an Organizational Client.
- - - Targeted Outreach An outreach activity tied to a specific client. For example: law enforcement has a list of high-risk individuals that county MH is reaching out to in order to get them into treatment.
- - - Quality Improvement Activities Any type of Quality Improvement and/or administrative time, such as chart review, attending a QI-related meetings, etc.
- - - Consults to External Providers (Non-billable) Documents consults with physical health care providers, primary care providers or other relevant healthcare providers.
- - - Transportation Documents services that are strictly transportation-related. If a billable service was provided during the transport, the appropriate billable procedure code should be selected.
- - - Client Non Billable Srvc Must Document Any other non-billable service that must be documented and is not better accounted for by other available non-billable procedure codes.
- - - Prev Prob Identification-AOD Used to track SABG funded primary prevention activities using this strategy
- - - Prev Education-AOD Used to track SABG funded primary prevention activities using this strategy
- - - Prev Community Based-AOD Used to track SABG funded primary prevention activities using this strategy
- - - Prev Info Dissemination-AOD Used to track SABG funded primary prevention activities using this strategy
- - - Prev Environ Strategy-AOD Used to track SABG funded primary prevention activities using this strategy
- - - Prev-Alternatives-AOD Used to track SABG funded primary prevention activities using this strategy
- - - Quality Assurance-AOD Used to track SABG funded quality assurance activities
Y Y Y Transportation Mileage Mobile Crisis Add On - Used when transporting a client to a treatment facility; measures mileage
Y Y Y Transportation, Staff Time Mobile Crisis Add On - Used when transporting a client to a treatment facility OR when accompanying a client being transported by law enforcement, ambulance, or other valid transportation method; measures time spent during the transportation
- - - Inpatient Psychiatric Procedure Used to document a non-billable psychiatric procedure done in an inpatient unit
- - - Shift Summary Used to document a Shift Summary note when a client is in an inpatient or residential facility. This is a non-billable service, as the services will be bundled for these facilities.
- - - Non-Billable Bed Procedure Used to track non-billable bed days or bed procedures not otherwise captured elsewhere for facilities that do bed management (IP/CSU/Res)
- - - Brief Contact Note Used to document a brief, non-treatment services contact with the client, such as confirming an appointment.
N Y N Ambulatory Withdrawal Management Alcohol and/or drug services; ambulatory detoxification.
- - - Residential Daily Note Used to document your daily summary note for residential services.
N N Y Crisis Inquiry To be utilized in no-episode programs for crisis calls. This bills the same as Crisis Intervention.
- - - Non-Billable Attempted Contact To be utilized when documenting attempts to contact a client but have been unsuccessful in reaching them.
N Y N Residential Withdrawal Management SUD Residential Withdrawal Management day service
N Y N Partial Hospitalization-Substance Use S0201: Partial Hospitalization Services; less than 24 hours, per diem (DMC-ODS ONLY).
- - - Attestation Note Used for attendings if they want to add any additional context to the original note by residents/NP. We recommend attaching this note to the original note written by the resident/NP.
- - - Medical Non-Billable Note Used for documenting clinical and medical activity for which there is no existing code. (eg. reviewed, labs, charts, and messages without any patient or with other care providers interactions and/or when reviewing hospital records, it was not in conjunction with influencing the diagnosis).
- - - Legal Report Writing Note Used when writing reports or documentation for court or legal procedings, including LPS Conservatorship assessments, JV220s, or other court-related documents. This is also used for other reports, such as making CPS or APS reports, entering state reporting items, or writing grant-required reports for a specific client.
- - - CARE Act - Notice Activity Used when a staff member is drafting noticies for CARE Act processes, including all hearing and appearance notices, CARE Agreement notices, etc.
- - - CARE Act - Outreach and Engagement Used for documenting all outreach and engagement activities required to engage the respondent. Also used when developing a CARE Agreement with the respondent.
- - - CARE Act - Court Report Activity Used when a staff member is drafting needed reports for CARE Act processes, including CARE Agreement, Clinical Evaluation, CARE Plan, etc.
- - - CARE Act - Hearing Time Used to document activities that occur and time spent during CARE Act hearings.
Y Y Y Mobile Crisis Encounter Used when the Mobile Crisis Team is dispatched to a site to address a person's crisis. This is a bundled service and will bill a flat rate regardless of time indicated. It is recommended that staff continue to track the time spent on each encounter.
Y Y Y Mobile Crisis Dispatch Screening Used to document the screening provided to determine if the Mobile Crisis Team is dispatched to a location or not.
Y Y Y Mobile Crisis Follow-Up Used to document required follow-ups for Mobile Crisis Encounter.
- - - CARE Act - Data Reporting Used for data reporting activities related to the CARE Act
N N Y PEI Outreach Used to track MHSA PEI outreach activities. This will often use a pseudo-client, as many are not targeted to a specific client, but rather community-held outreach events.
- - - Room and Board Used to track Room and Board services. These aren't billable to Medi-Cal but may need to be tracked for other reimbursement or tracking purposes.
- - - Bed Hold Day Non-billable code to use when you're holding a bed for a specific client, but they're currently not occupying that bed.

Updated 4/9/24