2017 Coding Cheat Sheet Introduction Documenting services in our electronic health record serves multiple purposes: Creates a legal document that is the clinical record of the treatment clients receive Identifies for the billing office what services to bill for (either to Medicaid, a third-party insurance company, or the clients themselves) Helps to track productivity for staff Because the notes you write are such a vital part of the work that you do, please use this and your manager as guides to help you determine best disposition codes when completing your notes. Additional details for each code listed can be found in the Uniform Services Coding Manual found on MyWeb – so please make sure to become familiar with those details as well. When documenting your services, please keep the following guidelines in mind: 1. As much as possible, write your notes from the task bar of Mindlinc. 2. When documenting, please ensure you add the clinic where the service occurred from the drop-down menu. 3. Always document the actual number of minutes you spent providing the service – not what you think the service requires for billing purposes. Up-coding the time a service takes is considered fraud. 4. Become familiar with the codes that are available to you based on the location of the service (for some services they are only allowed in an office and not in the field). 5. Only use codes that are approved for your credentials or job title (i.e., peer specialist, bachelor’s level, etc.). 6. Lastly, from the Trauma Informed Care Committee, when completing documentation, always consider that your client will read what you write. Are your words and your language respectful? Are you writing concisely in a way that protects your client’s privacy, yet provides the necessary medical documentation? Consider who the records may be released to (other health providers, courts, clients) and what information may be damaging to share in excessive detail. Better yet, complete your documentation collaboratively with your client. Table of Contents Screening / Assessment / Prevention Codes ……………………………………………………………………………………… page 1 Treatment / Psychotherapy Codes ……………………………………………………………………………………………………. page 5 Crisis Codes ………………………………………………………………………………………………………………………………………. page 14 Additional / Non-billable Codes ………………………………………………………………………………………………………… page 16
Transcript
2017 Coding Cheat Sheet
Introduction
Documenting services in our electronic health record serves multiple purposes:
Creates a legal document that is the clinical record of the treatment clients receive
Identifies for the billing office what services to bill for (either to Medicaid, a third-party insurance company, or the clients
themselves)
Helps to track productivity for staff
Because the notes you write are such a vital part of the work that you do, please use this and your manager as guides to help you determine best
disposition codes when completing your notes. Additional details for each code listed can be found in the Uniform Services Coding Manual found
on MyWeb – so please make sure to become familiar with those details as well. When documenting your services, please keep the following
guidelines in mind:
1. As much as possible, write your notes from the task bar of Mindlinc.
2. When documenting, please ensure you add the clinic where the service occurred from the drop-down menu.
3. Always document the actual number of minutes you spent providing the service – not what you think the service requires for billing
purposes. Up-coding the time a service takes is considered fraud.
4. Become familiar with the codes that are available to you based on the location of the service (for some services they are only allowed in an
office and not in the field).
5. Only use codes that are approved for your credentials or job title (i.e., peer specialist, bachelor’s level, etc.).
6. Lastly, from the Trauma Informed Care Committee, when completing documentation, always consider that your client will read what you
write. Are your words and your language respectful? Are you writing concisely in a way that protects your client’s privacy, yet provides the
necessary medical documentation? Consider who the records may be released to (other health providers, courts, clients) and what
information may be damaging to share in excessive detail. Better yet, complete your documentation collaboratively with your client.
Behavioral health screening (H0002) MindLinc Code: BHSCR, Behavioral Health Screening Or Alcohol and/or drug screening A preliminary procedure limited in nature and intended to merely indicate whether there is a probability that a mental health and/or substance use-related problem is present. Screening may be accomplished using a structured interview or a formal standardized screening tool that is culturally and age-relevant.
1. The reason for the visit/call. What was the intended goal or agenda? Chief complaint/presenting concern(s) or problem(s) 2. Referral source and reason(s) for referral 3. Description of the service 4. Review of psychosocial and family history, identified risks, assessment of treatment program appropriateness 5. Plan for next contact(s) including any follow-up or coordination needed with 3rd parties and disposition – need for BH services, referral, etc. Diagnosis: Not Required
Staff: Bachelor’s and above, not CAC I Locations: All Modes: Face-to-face, phone Notes: No time limitations
Intake – Psychiatric Diagnostic Evaluation: (90791) MindLinc Code: 90791, Intake Lic Psychiatric Diagnostic Evaluation is an integrated biophysical assessment, including history, mental status, and recommendations. The evaluation may include communication with family or other sources and review and ordering of diagnostic studies.
SEE INTAKE TEMPLATE Attached: 1. The reason for the visit. What was the intended goal or agenda? Chief complaint/presenting concern(s) or problem(s) 2. Referral source 3. Psychiatric diagnostic interview examination elements – SEE INTAKE TEMPLATE 4. Review of psychosocial, family and Tx history 5. Mental status exam 6. Diagnostic formulation 7. Plan for next contact(s) including any follow-up or coordination needed with 3rd parties and disposition Diagnosis: Not Required
provided prior to discharge. May include interactive complexity services. No time limitations
Assessment:(H0031) MindLinc Codes: H0031, Assessment Diag Assessment w/o psych testing Intake Assessment Non-Lic Specialized Assessment Disabilities Assessment (Not MD/APN) A face-to-face clinical assessment that identifies factors of mental illness, functional capacity, and other additional information used for the treatment of mental illness. Information may be obtained from collaterals. This assessment results in the identification of the patient’s BH service needs and recommendations for treatment.
1. The reason for the visit. What was the intended goal or agenda? Chief complaint/presenting concern(s) or problem(s) 2. Description of the service 3. Review of psychosocial and family history, client functioning and other assessment information 4. Plan for next contact(s) including any follow-up or coordination needed with 3rd parties and disposition – need for BH services, referral, etc.
Diagnosis: Not Required
Staff: Bachelor’s level
Locations:
All
Modes: Face-to-face
Notes:
If a Mental Status Exam and Diagnosis evaluation is
completed, it needs to be completed by staff with at
least the minimum requirements for a 90791.
Otherwise a deferred diagnosis should be used.
Licensed MHPs, when completing a full assessment
with mental status and diagnosis should use
procedure code 90791.
No time limitations
Behavioral health prevention education service: (H0025) Mindlinc Codes: WellSvc0, Wellness Service 0 WellSvc5, Wellness Service 5 WellSvc10, Wellness Service 10 WellSvc50, Wellness Service 50 Prevention/Education Service Family Wellness Service Group Therapy Wellness Schl Bsd SU Prev
1. The reason for the visit. What was the intended goal or agenda? 2. Description of the service 3. Prevention education provided and individual’s response to the information 4. Plan for next contact(s), if applicable Diagnosis: Not Required
Staff: All, including peers and bachelor’s level Locations: Office, home, school Modes: Face-to-face, telephone Notes: 0/5/10/50 indicate the fee; work with your manager to set the group fee, then choose the corresponding code. Education involves two-way communication and is distinguished from information dissemination by the
Services to individuals on issues of behavioral health education, to affect knowledge, attitude and behavior. It may include screenings to assist individuals in obtaining appropriate treatment. Prevention activities are delivered prior to the onset of a disorder and are intended to prevent or reduce the risk of developing a behavioral health problem. (SAMSHA). Causes and symptoms of disorders are discussed to encourage early intervention and reduce severity of illness.
fact that interaction between educator/facilitator and participants is the basis of the activities. No time limitations
Stress management classes, non-physician provider, per session: (S9454) Mindlinc Code: S9454 Stress Mgmt Class Structured classes designed to educate clients on the management of stress.
1. What was the intended class goal or agenda? 2. Description of the class material reviewed/presented and individual’s response to class Diagnosis: Not Required
Staff: Peers, bachelor level ok; master’s intern, unlicensed and licensed clinician, LPN, RN, APN, CAC II and III, LAC Locations: Office, school Modes: Face-to-face Notes: Must be face to face and in group setting (2 or more clients); no time limitations
Bx Health Outreach: (H0023) Mindlinc Code: A planned approach to reach a population within their environment for the purpose of preventing and/or addressing BH issues and problems. Services may include • Developing an alliance with a consumer to bring him/her into ongoing treatment • Re-engagement effort including utilizing drop-in center services
1. The reason for the visit/call. What was the intended goal or agenda? 2. Description of the service 3. Outreach services provided and the individual’s response 4. Plan for next contact(s) including any follow-up or coordination needed with 3rd parties, if applicable Diagnosis: Not Required
Staff: All, including peers and less than bachelor's Locations: All Modes: Face-to-face, phone Notes: Phone okay. Example Activities:
Initiating non-threatening conversation and informally identifying need for BH services, with
• Prevention/Intervention activities delivered to individuals and family These individuals may or may not have currently consented to receive services.
repeat contact over time in an effort to engage an individual into services
Respond to referrals as requested by police, landlords, etc., of individuals suspected of having an SMI/SPMI/SED and in need of BH services
Outreach to re-engage individuals who are at risk for disengaging from services
Minimum time 8 minutes, no max time
Bx Health Prevention Education Service: (H0025) Mindlinc Code: Delivery of services to individuals on issues of behavioral health education, to affect knowledge, attitude and behavior. It may include screenings to assist individuals in obtaining appropriate treatment. Causes and symptoms of disorders are discussed to encourage early intervention and reduce severity of mental illness. Education involves two-way communication and is distinguished from information dissemination by the fact that interaction between educator/facilitator and participants is the basis of the activities.
1. The reason for the visit. What was the intended goal or agenda? 2. Description of the service 3. Prevention education provided and individual’s response to the information 4. Plan for next contact(s), if applicable Diagnosis: Not Required
Staff: All, including peers and less than bachelor’s Locations: Office, home, school Modes: Face-to-face, telephone Notes: Education activity that involves interaction between facilitator and participants; not strictly information dissemination. No time limitations
Behavioral health counseling and therapy (H0004) Mindlinc Codes: H0004 Individual BH Counseling BHCPC: Individual BH Counseling: Phone - Client BHCPC: Individual BH Counseling: Phone – Parent SA-Ind BH counseling CAC Schl Bsd SU Screen Individual counseling/therapy outlined in the treatment/service plan. Problem(s) as identified by an assessment and listed in the treatment/service plan. The intended outcome is the management, reduction/resolution of the identified problem(s), change in the patient’s condition/service needs occurs.
1. The reason for the visit/call. What was the intended goal or agenda? How does the service relate to the treatment/service plan? 2. Description of the service provided 3. The therapeutic intervention(s) utilized and the individual’s response to the intervention(s) 4. How did the service impact the individual’s progress towards goals/objectives? 5. Plan for next contact(s) including any follow-up or coordination needed with 3rd parties Diagnosis: Required
Staff: Bachelor and above; No CAC I, but other CAC ok Locations: All Modes: Face-to-face, telephone Notes: Phone and phone with caregiver okay – choose most appropriate code in Mindlinc. Can be used with individuals or family groups; Minimum of 8 mins; H0004 may include unplanned telephone contact and/or planned contact if medically necessary, clinically justified, and included in the treatment/service plan. Minimum 8 minutes, no max time
Family Therapy: (90847) Mindlinc Code: 90847 Family Therapy Meeting with the patient’s family to evaluate and treat the patient’s condition. Family dynamics as they relate to the patient’s mental status and behavior are a focus of the session. Attention is also given to the impact the patient’s condition has on the family, with therapy aimed at improving the interaction between the patient and family members.
1. The reason for the visit/call. What was the intended goal or agenda? How does the service relate to the treatment plan? 2. Description of the service provided 3. The therapeutic interventions(s) utilized and the response to the interventions(s) with a focus on family dynamics 4. How did the service impact progress towards goals/objectives? 5. Plan for next contact(s) including any follow-up or coordination needed with 3rd parties Diagnosis: Required
Staff: Master’s intern, unlicensed clinician, unlicensed clinicians, no CAC or LAC Locations: All, except ERs Modes: Face-to-face Notes: Minimum of 26 mins, no max time. An open clinical record for each family member is not required, nor does each family have to be present in the family session
Mental health service plan development by non-physician: (H0032) Mindlinc Code: H0032 Service Plan Dev non-MD Activities to develop, evaluate, or modify a patient’s treatment/service plan, including the statement of individualized treatment/service goals, clinical interventions designed to achieve goals, and an evaluation of progress toward goals. The treatment/service plan is reviewed by the clinician and clinical supervisor, and revised with the patient as necessary or when a major change in the patient’s condition/service needs occurs.
1. The reason for the visit. What was the intended goal or agenda? 2. Description of the service (should include discussion of service plan development) 3. Completion of or substantial progress toward plan development including required signatures according to agency policies 4. Treatment plan revisions should include progress and/or completion of goals 5. Plan for next contact(s) including any follow-up or coordination needed with 3rd parties Diagnosis: Required
Staff: Bachelor's, master’s intern, unlicensed clinician, licensed clinicians, APN, No: CAC or LAC Locations: All except ERs Modes: Face-to-face Notes: Face-to-face only; Use only when whole focus of session is on Tx planning. If occurs within therapy session, better to code psychotherapy No time limitations
Family Therapy: (90847) Mindlinc Code: 90847 Family Therapy Meeting with the patient’s family to evaluate and treat the patient’s condition. Family dynamics as they relate to the patient’s mental status and behavior are a focus of the session. Attention is also given to the impact the patient’s condition has on the family, with therapy aimed at improving the interaction between the patient and family members.
1. The reason for the visit/call. What was the intended goal or agenda? How does the service relate to the treatment plan? 2. Description of the service provided 3. The therapeutic interventions(s) utilized and the response to the interventions(s) with a focus on family dynamics 4. How did the service impact progress towards goals/objectives? 5. Plan for next contact(s) including any follow-up or coordination needed with 3rd parties Diagnosis: Required
Staff: Master’s Intern, Unlicensed clinicians, Licensed Clinicians; LAC, APN, RxN, and MD, not bachelor's level or CAC Locations: Most locations, not jails or ERs Modes: Face-to-face Notes: Minimum of 26 mins, no max time. An open clinical record for each family member is not required, nor does each family have to be present in the family session
Family Therapy client not present (90846) Mindlinc Code: 90846 Family Therapy – w/o Client (Adlt or Chld) Meeting with the patient’s family to evaluate and treat the patient’s condition. Family
Same as Above Staff: Master’s intern, unlicensed clinicians, licensed clinicians; LAC, APN, RxN, and MDs, not bachelor's level or CACs;
dynamics as they relate to the patient’s mental status and behavior are a focus of the session. Attention is also given to the impact the patient’s condition has on the family, with therapy aimed at improving the interaction between the patient and family members.
Locations: All Modes: Face-to-face Notes: Minimum of 26 mins.
Family Therapy non-billable mbr Mindlinc Code: 90847NB – Family therapy Non-Bill Mbr Use this code when documenting the participation of a family member in family therapy session. Only one client is billed per family therapy session and this code should be used for the non-billable members.
Same as Family Therapy Staff: Master’s intern, unlicensed clinicians, licensed clinicians; LAC, APN, RxN, and MDs, not bachelor's level or CACs Locations: All Modes: Face-to-face Notes: Minimum of 26 mins.
Group psychotherapy: (90853) Mindlinc Code: 90853, Group Therapy Facilitating emotional and rational cognitive interactions in a group setting with 2/more patients (other than a family therapy session) in an effort to change the individual behavior of each person in the group through interpersonal exchanges. The group may include patients with separate, distinct, maladaptive disorders, or share some facet of a disorder with other people in the group (e.g., drug abuse, victims of violence). Goals relate to BH treatment, including the development of insight/affective understanding, the use of behavior modification techniques, the use of supportive interactions,
1. The reason for the visit. What was the intended goal or agenda? How does the service relate to the treatment/service plan? 2. Description of the service provided including number of patients present. 3. The therapeutic intervention(s) utilized and the response to the intervention(s). 4. How did the service impact progress towards goals/objectives? 5. Plan for next contact(s) including any follow-up or coordination needed with 3rd parties Diagnosis: Required
Staff: Master’s Interns, unlicensed clinicians, licensed clinicians, LAC, APN, RxN, and MDs; not bachelor's level Locations: Office, Schools Modes: Face-to-face Notes: Interactive Complexity eligible. All group notes must include number in group. Minimum: 45 min. (adult); 30 min. (children); maximum: N/A
the use of cognitive discussion of reality/any combination thereof to provide therapeutic change.
Multi-family Group Therapy: (90849) Mindlinc Code: 90849MF, Group Therapy, Multiple Fam Group Meeting with several patients’ families together to address similar issues of the patients’ treatment. Attention is also given to the impact the patients’ conditions have on the families
1. The reason for the visit. What was the intended goal or agenda? How does the service relate to the treatment/service plan? 2. Description of the service provided including number members present. 3. The therapeutic intervention(s) utilized and response to the intervention(s). 4. How did the service impact progress towards goals/objectives? 5. Plan for next contact(s) including any follow-up or coordination needed with 3rd parties 6. If the identified patient is not present for the group the progress note for the group session needs to describe why the patient was not present. The explanation should include the clinical reasoning as to why the patient was not part of the group and how therapy group is necessary for the covered diagnosis. Diagnosis: Required
Group Therapy non-billable member Mindlinc Code: 90849NB – Group Therapy-Non-Bill MBR
Same as for Group Therapy Same as for Group Therapy
Targeted case management: (T1017) Mindlinc Codes: 90882, Case Mgmt 90882, Case Mgmt-Family Contacts 90882PCP, PCP Contact
1. The reason for the visit/call. What was the intended goal or agenda? How does the service relate to the treatment plan? 2. Description of the service provided (specify issues addressed (adult living skills, family, income/ support, legal, medication, educational,
Staff: Bachelor's, interns, licensed and unlicensed clinicians Locations: All
90882COR, Core Mental Health Coordination Services designed to assist and support a patient diagnosed with or being assessed for a mental health disorder, to gain access to needed medical, social, educational, and other services as well as provide care coordination and care transition services, including:
Assessing service needs – gathering patient history/collateral info, treatment needs;
Treatment/Service plan development – specifying goals and actions to address patient needs, ensuring participation, identifying a course of action; includes transition plan development
Referral and related activities to obtain needed services – arranging initial appointments for patient with service providers/informing patient of services and/providing contact information for available services; working with patient/collaterals to secure access to services, including contacting agencies for appointments/services after initial referral process; and
Monitoring and follow-up – contacting patient/others to ensure patient is following the agreed upon service or transition plan and monitoring progress and impact of plan.
housing, interpersonal, medical/dental, vocational, other basic resources) 3. The services utilized and the individual’s response to the services (includes assessing service needs, service plan development, referral, and monitoring/follow-up, which includes care coordination) 4. How did the service impact the individual’s progress towards goals/objectives? 5. Plan for next contact(s) including any follow-up or coordination needed with 3rd parties Diagnosis: Required
Modes: Face-to-face, telephone Notes: Phone okay; individual, but not group; minimum time 8 minutes, no max time BA-Level staff may ONLY perform service if at a Licensed Mental Health Center and under direction of a physician per Medicaid State Plan Amendment.
Core Mental Health Coordination Same as Targeted Case Management Same as Targeted Case Management Notes: Clients with County Core auth only
Psychosocial rehabilitation services: (H2017) Mindlinc Code: H2017 Psysoc Rehab Svc, per 15 min An array of services, rendered in a variety of settings, designed to help patients capitalize on personal strengths, to develop coping strategies and skills to deal with deficits, and to develop a supportive environment in which to function as independently as possible. PSR differs from counseling and psychotherapy in that it focuses less on symptom management and more on restoring functional capabilities. The focus is on direct skills teaching, practicing/coaching and skills building, developing community living competencies (e.g., self-care, cooking, money management, personal grooming, maintenance of living environment)
1. The reason for the visit. What was the intended goal or agenda? How does the service relate to the treatment/service plan? 2. Description of the service and how the service is designed to increase functioning 3. The therapeutic intervention(s) utilized and the individual’s response to the intervention(s) 4. How did the service impact the individual’s progress towards goals/objectives? 5. Plan for next contact(s) including any follow-up or coordination needed with 3rd parties Diagnosis: Required
Staff: Most Staff can use including peers and bachelor level; not for CAC I, II, or III or LAC Locations: Office, mobile, school, home; not ERs Modes: Face-to-face, phone Notes: /Examples: Identification and management of situations and symptoms to reduce the frequency, duration, and severity of relapses · Gaining competence regarding how to respond to a psychiatric crisis · Gaining competence in understanding the role medication plays in the stabilization of the individual’s well-being · Development of a crisis plan · Identification of existing natural supports for addressing personal needs (e.g., families, employers, and friends) · Identification and development of organizational support, including such areas as sustaining personal entitlements, locating and using community resources or other supportive programs Minimum 8 minutes up to 4 hours 7 minutes
Psychoeducational Service: (H2027) Mindlinc Code: H2027, Psychoed Svc. per 15 min Activities rendered by a trained MHP to provide information and education to patients, families, and significant others regarding mental illness,
1. The reason for the visit/call. What was the intended goal or agenda? How does the service relate to the treatment/service plan? 2. Description of the service; education provided 3. How did the patient/family education impact the individual’s progress towards goals/objectives?
Staff: Most, including peers and bachelor’s; not for CAC or LAC Locations: Office, mobile, home, school Modes: Face-to-face, telephone
including co-occurring disorders, and treatment specific to the patients.
4. Plan for next contact(s) including any follow-up or coordination needed with 3rd parties Diagnosis: Required
Notes: Phone okay; individual, group, and family all ok. Minimum 8 minutes, no max time
Community psychiatric supportive treatment, face-to-face, per 15 minutes: (H0036) Mindlinc Code: Community Support 15 min Comprehensive Psychiatric Support Treatment (CPST) services consist of mental health rehabilitation/resiliency services. A team-based approach to the provision of treatment, rehabilitation/resiliency and support services. Therapeutic interventions are strengths-based and focus on promoting symptom stability, increasing the consumer’s ability to cope and relate to others and enhancing the highest level of functioning in the community.
1. The reason for the visit. What was the intended goal or agenda? How does the service relate to the treatment/service plan? 2. Description of the service and how activity is designed to increase functioning in the community 3. The therapeutic intervention(s) utilized and the individual’s response to the intervention(s) 4. How did the service impact the individual’s progress towards goals/objectives? 5. Plan for next contact(s) including any follow-up or coordination needed with 3rd parties Diagnosis: Required
Staff: Most staff including peers, bachelor’s, interns, licensed and unlicensed clinicians; no CAC or LAC Locations: Office, mobile, home, school Modes: Face-to-face Notes: Example Activities:
Symptom assessment and management (i.e., ongoing assessment, psycho-education, and symptom management efforts) Supportive counseling and psychotherapy on a planned and as needed basis
Encourage engagement with peer support services
Development of discharge/transition goals and related planning
Advocating on behalf of patients
Crisis intervention
Medication training and monitoring Educating regarding symptom management Facilitating access to health care
Skills teaching to help client meet transportation needs or access transportation services
Help finding and keeping safe, affordable housing
Home visits Minimum time 8 minutes up to 4 hours 7 minutes
Skills training and development, per 15 minutes (H2014) Mindlinc Codes: Skills Training and Development, Coaching Therapeutic activities designed to reduce/resolve identified barriers and improve social functioning in areas essential to establishing and maintaining a patient in the community (e.g., home, peer group, work/school). Activities address the specific needs of the patient by promoting skill development and training, which reduces symptomatology and promotes community integration and job readiness. NOT for CHILDREN 6 and UNDER
Service Content 1. The reason for the visit/call. What was the intended goal or agenda? How does the service relate to the treatment/service plan? 2. Description of the service and how service is designed to increase functioning in the community 3. The therapeutic activities utilized and the individual’s response 4. How did the service impact the individual’s progress towards goals/objectives? 5. Plan for next contact(s) including any follow-up or coordination needed with 3rd parties Diagnosis: Required
Staff: Peer Specialists Locations: Office, home, school Modes: Face-to-face, telephone Example Activities: ● Development and maintenance of necessary community and daily living skills (i.e., grooming, personal hygiene, cooking, nutrition, health and MH education, money management and maintenance of living environment) ● Development of appropriate personal support networks to diminish tendencies towards isolation and withdrawal ● Development of basic language skills necessary to enable patient to function independently ● Training in appropriate use of community services Minimum time 8 minutes up to 8 hours
Self-care/home management training (97535) Mindlinc Code: 97535 Self-care/home management training Direct one-on-one contact in which the provider instructs and trains a patient in the performance of essential self-care and home management activities related to his/her ability to function in the community. Activities are designed to address the specific needs of the patient,
1. The reason for the visit. What was the intended goal or agenda? How does the service relate to the treatment/service plan? 2. Description of the service and how service increases ADLs and ability to function in the community and patient response to service 3. How did the service impact progress towards goals/objectives? 4. Plan for next contact(s) including any follow-up or coordination needed with 3rd parties
Staff: All, except for CAC and LAC Locations: Office, home, mobile, school Modes: Face-to-face Notes: Clients age 18+ Patient requires supervised training to help perform his/her normal Activities of Daily Living (ADLs), due to
including but not limited to Activities of Daily Living (ADLs) and compensatory training for impairments, meal preparation, safety procedures, and use of assistive technology devices/adaptive equipment.
Diagnosis: Required
impairment resulting from Intellectual or Developmental Disability (IDD), or behavioral health illness. There is reasonable expectation that the patient’s functional level will improve as a result of this service Minimum 8 minutes up to 8 hours
Activity therapy, per 15 minutes (H2032) Mindlinc Code: H2032, Activity Therapy – per 15 min H2032 Activity Therapy, Group Activity therapy includes the use of music, dance, creative art or any type of play, not for recreation, but related to the care and treatment of the patient’s disabling behavioral health problems. These are therapeutic activities in a structured setting designed to improve social functioning, promote community integration and reduce symptoms in areas important to maintaining/re-establishing residency in the community.
1. Reason for the visit. What was the intended goal or agenda? How does the service relate to the treatment/service plan? 2. Description of activity 3. How did the service impact the individual’s progress towards goals/objectives? 4. Plan for next contact(s) including any follow-up or coordination needed with 3rd parties Diagnosis: Required
Staff: Bachelor’s, interns, licensed and unlicensed clinicians; no CAC or LAC Locations: Office, home, mobile, school Modes: Face-to-face Examples:
Playing basketball with group of adolescents to facilitate prosocial behavior and passing/taking turns.
Hiking in community to help a patient with depressive symptoms reinforce the connection between healthy mind and body with exercise.
Puppet play with a child to identify feelings and interpersonal dynamics
Art/music activities to improve self-esteem, concentration, etc.
Minimum 8 minutes – no max time limit
Community/work reintegration training (97537) Mindlinc Code: 97537 Community/Work Reintegration
1. The reason for the visit. What was the
intended goal or agenda? How does the service relate to the treatment/service plan? 2. Description of the service and how the service is designed to increase community/work functioning and patient response
Staff: Bachelor’s, interns, licensed and unlicensed clinicians; no CAC or LAC Locations: Office, mobile, home, school
Direct one-on-one contact in which the provider instructs and trains a patient in the performance of essential Activities of Daily Living (ADLs) related to his/her ability to function in the community and to reintegrate into the work environment. Activities are designed to address the specific needs of the patient including but not limited to shopping, transportation, money management, avocational activities and/or work environment/modification analysis, work task
analysis, and use of assistive technology devices/adaptive equipment.
3. How did the service impact the individual’s progress towards goals/objectives? 4. Plan for next contact(s) including any follow-up or coordination needed with 3rd parties Diagnosis: Required
Modes: Face-to-face Notes: Ages 18 and older only Patient requires supervised training to help perform essential Activities of Daily Living (ADLs) related to his/her ability to function in the community and to reintegrate into the work environment, due to impairment resulting from Intellectual or Developmental Disability (IDD), injury, or behavioral health illness. There is reasonable expectation that the patient’s functional level will improve as a result of this service. Examples:
Applying for transportation assistance by planning bus route and stop times, scheduling transportation service rides, practicing route to and from work site.
Resume, interview, and job coaching skills to obtain employment and ensure success.
Review and address hygiene, proper dress attire, interpersonal skills and expectations for workplace environment.
Unanticipated services rendered in the process of resolving a client crisis, requiring immediate attention, that without intervention, could result in the client requiring a higher LOC., Services include: immediate crisis intervention to de-escalate the individual or family in crisis, assess dangerousness of situation, determine risk of suicide or danger to others, assess access to or ability to utilize support, triage, assess for and facilitate admission to higher level care or additional forms of treatment if needed to stabilize the immediate situation, . When possible, if the client has developed a Wellness Recovery Action Plan (WRAP) and/or psychiatric advance directive, this plan is followed with the client’s permission.
1. The reason for the visit/call. What was the intended goal or agenda? Description of the crisis/need for crisis intervention 2. The therapeutic intervention(s) utilized (assessment, mental status, de-escalation techniques, consultation, referral, therapy) and the individual’s response to the intervention(s) 3. BH history 4. Treatment needs (immediate, short-term, long-term) linked with an existing crisis plan (WRAP, advance directive), if available 5. Other problems identified (mental health, substance abuse, medical, etc.) 6. Plan for next contact(s) including any follow-up or coordination needed with 3rd parties Diagnosis: Required
Staff: Bachelor's, interns, unlicensed and licensed clinicians, LAC Locations: All Modes: Face-to-face, telephone Notes: 8 minutes to 4 hours 7 minutes; Available on a 24-hour, 7-day a week basis. Services are provided by a mobile team/crisis program in a facility/clinic. May be provided by more than one direct care staff if needed to address the situation (e.g., for safety); all staff involved and their activities are identified and documented.
Crisis intervention mental health services: (S9485) Mindlinc Codes: CCGR4, Crisis Contact XLong In Person 4.25-8 hr.
1. The reason for the visit/call. What was the intended goal or agenda? Description of the crisis/need for crisis intervention
Staff: Bachelor's, interns, unlicensed and licensed clinicians, LAC
CCPhL Crisis Contact-Phone (4.25-8 hrs.) 4 hours Unanticipated services rendered in the process of resolving a client crisis, requiring immediate attention, that without intervention, could result in the client requiring a higher LOC., Services include: immediate crisis intervention to deescalate the individual or family in crisis, assess dangerousness of situation, determine risk of suicide or danger to others, assess access to or ability to utilize support, triage, assess for and facilitate admission to higher level care or additional forms of treatment if needed to stabilize the immediate situation. When possible, if the client has developed a Wellness Recovery Action Plan (WRAP) and/or psychiatric advance directive, this plan is followed with the client’s permission.
2. The therapeutic intervention(s) utilized (assessment, mental status, de-escalation techniques, consultation, referral) and the individual/family’s response to the intervention(s) 3. BH history 4. Treatment needs (immediate, short-term, long-term) linked with an existing crisis plan (WRAP, advance directive), if available 5. Other problems identified (mental health, substance abuse, medical, etc.) 6. Plan for next contact(s) including any follow-up or coordination needed with 3rd parties Diagnosis: Required
Locations: All Modes: Face-to-face, telephone Notes: Minimum of 4 hours 8 minutes; Available on a 24-hour, 7-day a week basis. Services are provided by a mobile team/crisis program in a facility/clinic. May be provided by more than one direct care staff if needed to address the situation (e.g., for safety); all staff involved and their activities are identified and documented.
Additional Codes – Non-Billable
Client Late Cancellation: Used when cancellation from client came less than 24 hours prior to appointment
For Medicaid clients, documentation of outreach is required. Please refer to BHI policy for required outreach efforts based on client's risk level at last contact
Client "No Show" for Appointment: Used when client does not show for appointment. For Medicaid clients, follow up with clients is required and should be documented
Mental Health Ctr Cancelled Appt Internal Consulting Internal Service Code Telephone Call - Non-Case Mgmt Notes: Can be used to document calls to schedule
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