Clinical Documentation Manual

CLINICAL
DOCUMENTATION
MANUAL
Revised June 2021

TABLE OF CONTENTS
CHAPTER 1. INTRODUCTION/COMPLIANCE .................................................................................... 4

1.1. WHY DO WE HAVE THIS MANUAL? ........................................................................................ 4
1.2. COMPLIANCE ......................................................................................................................... 5
1.3. UTILIZATION REVIEW ............................................................................................................ 6
CHAPTER 2. GENERAL PRINCIPLES OF DOCUMENTATION AND AUTHORIZATION TIMELINES . 7
2.1. GENERAL PRINCIPLES OF DOCUMENTATION ...................................................................... 7
2.2. SIGNATURES ............................................................................................................................ 9
CHAPTER 3. ESTABLISHMENT OF MEDICAL NECESSITY ............................................................. 11
3.1. THE FLOW OF CLINICAL INFORMATION .............................................................................. 11
3.2. THE GOLDEN THREAD .......................................................................................................... 12
3.3. MEDICAL NECESSITY ............................................................................................................ 12
3.4. COMPONENTS OF MEDICAL NECESSITY ............................................................................ 13
3.2. ASSESSMENT ......................................................................................................................... 15
CHAPTER 4. TREATMENT PLANNING ............................................................................................. 18
4.1. PARTNERSHIP PLAN FOR WELLNESS ........................................................................... 18
4.4. COMPONENT DETAILS AND EXAMPLES .............................................................................. 22
CHAPTER 5. UTILIZATION REVIEW TRACK .................................................................................... 29
5.1. ESTABLISHMENT OF THE UR TRACK/ TIMEFRAMES FOR SUBMISSION OF
DOCUMENTATION FOR INITIAL SERVICE AUTHORIZATION ...................................................... 29
5.2. ANNUAL RENEWAL OF SERVICES ....................................................................................... 30
CHAPTER 6. PROGRESS NOTES .................................................................................................... 31
6.1. GENERAL GUIDELINES FOR DOCUMENTING MEDICAL NECESSITY FOR PROGRESS
NOTES............................................................................................................................................. 32
6.2. TIMELINESS OF DOCUMENTATION OF SERVICES .......................................................... 34
6.3. FREQUENCY OF DOCUMENTATION .................................................................................. 34
6.4. PROGRESS NOTE SERVICE DEFINITION .......................................................................... 35
6.5. DISCHARGE SUMMARY ......................................................................................................... 44
6.6. NON-BILLABLE SERVICES ..................................................................................................... 45
6.7. LOCKOUTS AND LIMITATIONS .............................................................................................. 47
6.8. SERVICE TYPE COMPARISON .............................................................................................. 48
CHAPTER 7. SCOPE OF PRACTICE/COMPETENCE/WORK............................................................ 53
BHSD Clinical Documentation Manual, Rev. June 2021 Page 2 of 121
7.1. CCBHS-MHP PROFESSIONAL CLASSIFICATIONS AND LICENSES .................................... 54
9.1. MEDICATION CONSENTS ...................................................................................................... 58
CHAPTER 9. MEDICATION CONSENTS ........................................................................................... 58
9.2. MEDICATION DOCUMENTATION GUIDELINES .................................................................... 58
10.1. KATIE A. SUBCLASS............................................................................................................. 60
CHAPTER 10. SPECIAL POPULATIONS............................................................................................ 60
10.2. THERAPEUTIC BEHAVIORAL SERVICES (TBS) CLASS ..................................................... 61
11.1. SAMPLE STRENGTHS .......................................................................................................... 63
CHAPTER 11. WORDING SAMPLES ................................................................................................ 63
11.2. SAMPLE INTERVENTION WORDS ....................................................................................... 63
11.3. SAMPLE INTERVENTION PHRASES FOR SPECIFIC PSYCHIATRIC SYMPTOMS and
CONDITIONS................................................................................................................................... 63
11.4. SAMPLE PROGRESS NOTES .............................................................................................. 67
11.5. SAMPLE PARTNERSHIP PLAN GOALS ............................................................................... 72
APPENDICES ..................................................................................................................................... 74
APPENDIX A. MEDI-CAL DIAGNOSIS LISTS .................................................................................... 75
APPENDIX B. CCBHS-MHP OUTPATIENT INCLUDED DIAGNOSIS LIST ....................................... 77
APPENDIX C. TITLE 9 SERVICE DEFINITIONS................................................................................ 87
APPENDIX D. SCOPE OF PRACTICE DEFINITIONS........................................................................ 89
APPENDIX E. GUIDELINES FOR SCOPE OF PRACTICE .............................................................. 110
APPENDIX F. ABBREVIATIONS ...................................................................................................... 112
APPENDIX G. FORMS ..................................................................................................................... 121

CHAPTER 1. INTRODUCTION/COMPLIANCE
1.1. WHY DO WE HAVE THIS MANUAL?

This manual was developed as a resource for providers within the Contra Costa Behavioral Health
Services-Mental Health Plan (CCBHS-MHP), which includes County owned and operated programs and
Community Based Organizations (CBOs). It outlines standards and practices required within the
Children, Youth and Family; Katie A; Forensics; Transitional Services; and Adult & Older Adult systems
of care.
CCBHS-MHP establishes documentation standards in order to help realize the commitment to clinical
and service excellence. In addition, accurate and complete documentation protects providers from risk
in legal proceedings, helps maintain compliance with all regulatory requirements when claiming for
services, and enables professionals to discharge their legal and ethical duties.
CCBHS-MHP submits a claim for each covered service provided by each service provider. All services
are documented using Medi-Cal Specialty Mental Health documentation rules regardless of the client’s
Medi-Cal status. Services for clients with co-occurring mental health and substance use disorders are
documented using the rules presented in this manual.
This manual does not address specific documentation rules for services that are claimed to Drug
Medi-Cal Organized Delivery System (ODS) or to Medicare.
This Documentation Manual should be considered the CCBHS-MHP standard and is the source for all
documentation issues. The Utilization Review (UR) Team provides resources as well as trainings, guides
and other helpful documents. UR encourages questions and comments at any time.
This manual will be posted at the following website:
https://cchealth.org/mentalhealth/clinical-documentation/
Updates to this manual are done to address policy and regulation changes. When updates are available,
please be sure to replace old sections with updated sections.
Sources of information
This Clinical Documentation Manual is to be used as a reference guide and is not a definitive single
source of information regarding chart documentation requirements. This manual includes information
based on the following sources: Code of Federal Regulations (CFR) 45 and 42, the California Code of
Regulations (Title 9 and 22), California Department of Health Care Services (DHCS) Letters and
Information Notices, American Health Information Management Association (AHIMA), Contra Costa
County policies and procedures, directives & memos; and Quality Improvement & Utilization Review
Department’s interpretation and determination of documentation standards.

1.2. COMPLIANCE
Contra Costa Behavioral Health Services is a county behavioral health organization that provides
services to the community and then seeks reimbursement from state and federal funding sources. There
are many rules associated with billing the state and federal government, thus the need for this
documentation manual. In general, good ethical standards meet nearly all of the requirements. At times,
there is a need to provide some guidance and clarity so staff can efficiently and effectively document for
the services they provide.
The CCBHS-MHP Utilization Review Unit has adopted a compliance plan that is based on guidance and
standards established by the Office of Inspector General (OIG), US Department of Health and Human
Services. The OIG is primarily responsible for investigations of Medicare and Medicaid fraud and
provides support to the US Attorney’s Office for cases which lead to prosecution. The State of California
also has a Medicaid/Medicare Fraud Control Unit. Many California county behavioral health departments
have already been investigated by State and Federal agencies; and in all of those counties either severe
compliance plans or fraud charges have been implemented.
The intent of this compliance plan is to prevent fraud and abuse at all levels. The compliance plan
particularly supports the integrity of all health data submissions; as evidenced by accuracy, reliability,
validity, and timeliness. As part of this plan we must work to ensure that all services submitted for
reimbursement are based on accurate, complete, and timely documentation. It is the responsibility of
every provider to submit a complete and accurate record of the services they provide and to document
services in compliance with all applicable laws and regulations.
This manual reflects the current requirements for direct services reimbursed by Medi-Cal Specialty
Mental Health Services (Division 1, Title 9, California Code of Regulations (CCR)) and serves as the
basis for all documentation and claiming by CCBHS-MHP, regardless of payer source. All staff in County
programs, contracted agencies, and contracted providers are expected to abide by the information found
in this manual.
Compliance is accomplished by:
• Adherence to legal, ethical, code of conduct and best-practice standards for billing and
documentation
• Participation by all providers in proactive training and quality improvement processes.
• Providers working within their professional scope of practice.
• Having a Compliance Plan to ensure there is accountability for all CCBHS-MHP, Community
Programs activities and functions. This includes the accuracy of progress note documentation by
defined practitioners who will select correct procedure codes and services location to support the
documentation of services provided.

1.3. UTILIZATION REVIEW
State regulations and CCBHS-MHP policies specify that all beneficiary health records, regardless of
format (electronic or print), must go through the utilization review (UR) process. This process is meant to
ensure that all planned clinical services are appropriate to address the client’s behavioral health needs.
It is also meant to make sure that the records comply with all State and Federal regulations as well as
CCBHS-MHP policies. The Utilization Review process includes the evaluation and improvement of
services through the following practices:
• Standing Utilization Review
• Contract Provider and or Community Based Organization (CBO) Utilization Review
• Inpatient Utilization Review
• Medication Support Services Utilization Review
Utilization Management/UM has established a Utilization Review Committee (URC) with an aim to review
health records of CCBHS-MHP and its Community Based Organizations. The role of the UR reviewers
is critical as they provide clinical oversight and function as a “check and balance” system. The reviewers
are CCBHS-MHP Clinical health care professional who has appropriate clinical expertise that can
address the beneficiary’s behavioral health needs. Reviewers are responsible to ensure the following:
• All services meet Medical Necessity standards
• Planned services benefit the client by significantly diminishing the impairment or preventing
significant deterioration in an important area of life functioning
• All documents are completed within established CCBHS-MHP standards
Reviewers also monitor that client plans are written in client-centered language and include client
signature as evidence of client involvement. Utilizing a UR tool, reviewers provide feedback to the
Utilization Review Manager, who is responsible for tracking any findings, following up on any quality
issues, and identifying items for disallowance.

CHAPTER 2. GENERAL PRINCIPLES OF DOCUMENTATION
AND AUTHORIZATION TIMELINES
2.1. GENERAL PRINCIPLES OF DOCUMENTATION

1. All Providers must refer and adhere to CCBHS-MHP Policy 709-MH, Quality
Management/Utilization Review: Documentation Standards.
2. All CBOs who currently utilize an Electronic Health Record (EHR) must adhere to the UR Signature
Certification memo of June 1, 2016, regarding EHRs and electronic signatures.
3. All Providers must use CCBHS-MHP-approved forms and templates. Contract providers who
utilize an electronic health record system for documentation must incorporate all CCBHS-MHP
required documentation elements identified in CCBHS-MHP’s Policy 709-MH.
4. Required clinical documents, once entered into the medical record, become part of a legal
document. Therefore, the following are not permitted: removal of pages from the record, erasing or
amending notes that have already been entered/filed, and/or destroying the content of the medical
record.
5. Services can only be entered for billing if there is a corresponding progress note.
6. All services shall be provided by staff within the scope of practice of the individual delivering the
service. Licensed clinicians will follow specific scope of practice requirements as determined by
the applicable license regulations of their governing board.
7. Each progress note should provide enough detail so that auditors and other service providers can
easily ascertain the service provided, the client’s current status, and needs without having to refer
to previous progress notes. Each progress note must stand “alone”.
8. Each progress note must show that the service met “medical and service necessity” criteria
9. Progress notes should clearly indicate the type of service provided and how the service is to
address an identified area of impairment, and the progress (or lack of progress) in treatment.
10. Clinical documentation must incorporate the concept of the “Golden Thread”. The Golden Thread
is the documentation that supports each decision, intervention, or client note that contributes to a
complete record of client care that is error free and ready for reimbursement.
The Golden Thread begins with the clinical assessment (identified needs), then pulls through
the treatment plan (interventions and goals) to on-going progress notes (client effort, service
provided, progress made towards goals).
11. It is crucial that the staff providing the service identify and selects the correct procedure code for
the service provided and that the documentation supports and substantiates this service. This
ensures that CCBHS-MHP receives the correct reimbursement for services provided.

12. Some services while necessary for the well-being of the client are not billable to the State. Non-
billable (540) and non-billable lock out (580) codes block a service from being billed. Non-billable
services are meant to include a wide variety of potential services deemed helpful or necessary to
the client but are not reimbursable by the State as a mental health service. These services should
be documented by staff working with clients.
13. Non-Billable Services Include, but are not limited to: transportation of the client, sending or
receiving a fax, listening to voicemails, leaving voicemails, scheduling appointments, or
interpretation/ translation services.
14. NOTE: “Travel” is not “Transportation”.
Travel is when a provider travels from their office location to a field location to provide a
mental health service.
Transportation is when a provider drives a client/family member to and from a location.
without provision of a mental health service (such as to or from a doctor’s appointment or to
pick up a check or medication). If a mental health service is provided while transporting a
client, then the time spent providing the mental health service during transportation may be
billed.
15. “Elapsed Time” billed should be documented on each progress note. Elapsed time is billed in
minutes, and it includes:
a. Time spent providing services to the client (i.e., on the phone, face to face, in the field, etc.).
b. Documentation time (maximum of 15 minutes is generally considered reasonable).
c. Travel time between the work site and the place where services were rendered.
16. Please remember to bill for “actual” time spent providing a service to the client. Do not bill “blocks
of time” (e.g., an hour for weekly individual therapy sessions).
17. Each service contact is documented in a progress note and documentation must be completed in
a timely manner. A progress note is completed for each service contact, except for Psychiatric
Emergency Services, Crisis Residential Services, and Day Treatment Services.
a. PROGRESS NOTE TIMELINE: Progress notes must be completed in a timely manner
according to the following guidelines:
i) Every effort should be made to complete progress notes on the same day of service.
ii) Progress notes should be completed within three (3) business days from the delivery
of service.
iii) If the progress note is not completed within three (3) business days, the clinician must
write “late entry” on the progress note.
iv) Please remember, documentation time may not be included in the total time billed if the
progress note was written more than three (3) business days after service delivery.

18. For group notes, staff must detail the purpose of the group and individualize the note for each client.
Documentation must include how the client benefitted from the group, the client’s participation, and
their individual response to the interventions provided during the group.
19. If a service is provided by multiple staff, each staff is required to complete their own progress note
documenting their role in the provision of the service and detailing the specific interventions/
services they provided.
20. Documentation must be legible. Ensure that the spell check function is turned on. Documentation
that is not legible is at risk for disallowance
21. APS/CPS Reports, Incident Reports, Unusual Occurrence Forms, Grievances, Notice of Adverse
Benefit Determination, Utilization Review Committee recommendations or forms and audit
worksheets shall never be filed in the medical record or billed. Questions regarding other forms
(not already listed) and their inclusion into the medical record should be directed to QI/UR staff.
22. Confidentiality: Do not write another client’s full name in a client’s medical record. If another client
must be identified in the record do not identify that individual as a behavioral health client unless
necessary. Names of family members or support persons should be recorded only when needed
to complete intake registration and financial documents; otherwise, refer to the relationship -
mother, husband, friend - but do not use names. It is acceptable to use first name or initials of
another person when needed for clarification.
23. Copy and paste: Do not copy and paste text into a client’s medical record. Each note needs to be
specific to the service provided. If you are using a template that brings forward text from a previous
progress note, the narrative must be changed to reflect the current service being provided.
Progress notes that are submitted and appear to be worded exactly like, or too similarly to, previous
entries may be assumed to be a duplication of service, i.e., containing inaccurate, outdated, or false
information: therefore, claiming associated with these notes could be considered fraudulent.
2.2. SIGNATURES
Clinical staff signatures are a required element of most clinical documents. At a minimum, signatures
must include the first initial of the first name, the full last name, licensure and/or designation (e.g., ASW,
MD, LMFT, MHRS, DMHW, PhD waivered, etc.), and date of signature.
For those agencies using an EHR, the electronic signature of the service provider will be accepted and
considered valid as long as the agency has a current and valid “Electronic Signature Certification” form
on file with Contra Costa County.
For forms that require client signatures, their signatures may be either electronic or “wet” signatures.
2.2.1. CO-SIGNATURES
Co-signatures for some staff may be required for several reasons. DHCS requires that some documents
(e.g., client plans) be approved by a Licensed Clinician. Additionally, County policy requires that some
documents be reviewed and co-signed by a supervisor as part of the authorization process. Also, some
staff are required to have progress notes co-signed for specific or indefinite periods. For example, new
and reassigned staff may be required to have co-signatures. Other co-signature requirements may be
assigned for purposes of quality assurance and/or compliance. Staff should consult with their supervisor
for additional specifics and refer to the most recent CCBHS-MHP Guidelines for Scope of Practice
(Appendix D)

CHAPTER 3. ESTABLISHMENT OF MEDICAL NECESSITY
3.1. THE FLOW OF CLINICAL INFORMATION

As each client begins services with CCBHS-MHP, there is a flow of information designed to support staff
in providing services that help the clients meet their mental health goals. The concept of the Golden
Thread should be apparent through the clinical documentation.
1. Assessment
5. Progress 2. Clinical
Notes/Interventions Formulation
Medical
Necessity
4. Partnership Plan 3. Diagnosis
1. The Clinical Assessment is the first step toward establishing Medical Necessity and the start of
services.
2. The Assessment supports staff in developing a Clinical Formulation that supports the diagnosis.
3. The Diagnosis records the areas of need and supports Medical Necessity.
4. The Partnership Plan creates a framework for the services we provide. Together with clients,
providers develop goals and planned interventions and treatments that support the clients in their
recovery.
5. Each documented intervention/service in progress notes shall link back to an issue identified on
both the Partnership Plan and the Assessment.

Throughout the course of treatment, from initial assessment to discharge, all services are based on
Medical Necessity. Every billable service provided must have documented support reflecting that the
service is medically necessary.
3.2. THE GOLDEN THREAD

WHAT IS THE GOLDEN THREAD?
The golden thread begins with the assessment (identified needs), then pulls
through the treatment plan (interventions and goals) to ongoing progress notes
(client efforts, services provided, progress made).
It is golden because, if accurately followed through, the documentation that supports each decision,
intervention, or client progress note contributes to a complete record of client care that is error-free and
ready for reimbursement.
Each piece of documentation must flow logically from one to another so that someone reviewing the
record can see the logic.
Documentation Linkage - a “Reflection” of the Golden Thread

Assessing the Client Completing the Assessment Form
Planning with the Client Completing the Service Plan
Working with the Client Writing Progress Notes
3.3. MEDICAL NECESSITY

Medical Necessity is established through the Assessment, while appropriate services are identified
through the Partnership Plan (Treatment Plan) process. Diagnosis and identification of the client’s
functional impairments further strengthen and reaffirm the need for behavioral health services that
support the client’s and family’s road to recovery. Medical Necessity must be established prior to the
provision of Specialty Mental Health Services.
During the assessment process, the clinician should identify mental health symptoms that are serious
enough to disrupt the client’s ability to cope and perform various age- and culturally-related social,
personal, occupational, scholastic, or behavioral functions. The service provider should identify the
client’s areas of life functioning that are impacted by their behavioral health. Examples are listed below.
• Problems with primary support group
• Problems related to the social environment
• Educational problems
• Occupational problems
• Housing problems
• Economic problems
• Problems with access to healthcare services
• Problems related to interaction with legal system/crime
• Other psychological or environmental problems
A medically necessary service is one that attempts to impact a functional impairment

brought about by a symptom of an included diagnosis.
Partnership Plan
Document behavioral
includes goals/objectives
changes and progress
Clinical formulation for based on
Assessment towards goals/objectives
Medical Necessity behaviors/symtoms/imp
on pogress notes based
airment that determined
on Medical Necessity
Medical Necessity
3.4. COMPONENTS OF MEDICAL NECESSITY

According to Title 9, CCR §1830.205, to be eligible for Medi-Cal
reimbursement for Outpatient/Specialty Mental Health Services, a service See Appendix B
must meet the following three criteria for Medical Necessity: for current
CCBHS-MHP ICD-
• Included Diagnosis Criteria. 10-DSM-5
• Functional Impairment Criteria. Included
• Intervention Related Criteria. Crosswalk List
3.4.1. DIAGNOSTIC CRITERIA

The focus of the service should be directed to functional impairments related to an Included Diagnosis.
Refer to MHSUDS Information Notice 17-004 and MHSUDS Information Notice 16-051.
Please note that having a diagnosis that is not “included” does not exclude a client from receiving
services. Clients may receive services if they have an excluded diagnosis as long as an included
diagnosis is also present and is the primary focus of treatment or the primary diagnosis. Clinicians are
expected to include any substance-related diagnosis (as a secondary diagnosis) that presents.
HDHCS requires that all claims to the State shall utilize the DSM-5 diagnosis.

All clinical documentation (progress notes) must include both the DSM-5 diagnosis code and ICD-10
code. The Assessment must include the ICD-10 Code, the DSM-5 Code and the full DSM-5 diagnosis
narrative fully written out (for example, “Major Depressive Disorder” instead of “MDD”).
DIAGNOSIS & MENTAL STATUS

A diagnosis and mental status exam can only be provided by a physician, licensed psychologist, licensed
clinical social worker, licensed marriage and family therapist, or nurse practitioner with a Psychiatric
Certification. These clinicians are often referred to as an LPHA, Licensed Practitioner of the Healing Arts.
The LPHA is responsible for conducting the mental status exam and assigning the diagnosis. License-
eligible staff; including trainees, waivered psychologists or post-doctorate clinicians, associate social
workers, and associate marriage and family therapists; can also assign a diagnosis and complete the
mental status exam if under the supervision of a licensed clinician. Also, please see Appendix D, Scope
of Practice Grid, to see which license-eligible staff will require a co-signature.
CHANGE OF DIAGNOSIS
Diagnoses may be changed at any time during the course of treatment, and they should be reviewed and
updated annually or biannually in reassessments. If a change in diagnosis occurs, the diagnosing
clinician/NP/MD must submit a Change of Diagnosis Request Form (MHA-002) to update the diagnosis
in the ShareCare billing system.
3.4.2. IMPAIRMENT CRITERIA

The client must have at least one of the following as a result of the mental disorder(s) identified in the
diagnostic criteria:
1. A significant impairment in an important area of life functioning, or
2. A probability of significant deterioration in an important area of life functioning, or
3. Children also qualify if there is a probability that the child will not progress developmentally as
individually appropriate. Children covered under EPSDT qualify if they have a mental disorder that
can be corrected or ameliorated.
3.4.3. INTERVENTION RELATED CRITERIA

Must meet all conditions listed below:
1. The focus of the proposed intervention is to address the condition identified in impairment criteria
above.
2. It is expected the proposed intervention will benefit the consumer by significantly diminishing the
impairment, or preventing significant deterioration in an important area of life functioning; and/or for
children it is probable the child will be enabled to progress developmentally as individually
appropriate (or if covered by EPSDT, the identified condition can be corrected or ameliorated).
3. The condition would not be adequately responsive to physical healthcare-based treatment.

3.2. ASSESSMENT
The Assessment is the first step towards building a trusting and therapeutic relationship between the
client and service provider. The Initial Assessment is designed to provide a comprehensive clinical
picture of the client, to establish medical necessity, to help treatment teams and clients define goals and
objectives, and to fulfill State and Federal requirements.
The Initial Assessment is an important clinical tool to get a clear account of the current impairments in
life functioning. Providers have a responsibility to fully understand how culture and social context shape
an individual and family’s behavioral health symptoms, presentation, meaning and coping styles along
with attitudes towards seeking help, stigma and the willingness to trust.
Per DHCS, as assessment must include the following elements:
1. Presenting problem(s). The beneficiary’s chief complaint and history of presenting problem(s),
including current level of functioning, relevant family history, and current family information.
2. Relevant conditions and psychosocial factors affecting the beneficiary’s physical health including,
as applicable, living situation, daily activities, social support, cultural and linguistic factors.
3. History of trauma and exposure to trauma.
4. Mental health history. Previous treatments, including providers, therapeutic modalities (e.g.,
medications, psychosocial treatment) and response and inpatient admissions.
5. Medical History including:
a. Physical health conditions reported by the beneficiary or significant support person.
b. Name and address of current source of medical treatment.
c. For children and adolescents, the history must include prenatal, perinatal events and
relevant/significant development history.
6. Medications, including:
a. Information about medications the beneficiary has received, or is receiving, to treat mental
health and medical conditions, including duration and medical treatment.
b. Documentation of the absence or presence of allergies or adverse reactions to medications.
c. Documentation of informed consent for medications.
7. Substance Exposure/Substance Use. Past and present use of tobacco, alcohol, and caffeine, CAM
(complementary and Alternative Medications), and over-the-counter drugs, and illicit drugs.
8. Client and/or family strengths. Documentation of the beneficiary’s strengths in achieving client
plan goals related to their mental health needs and functional impairment(s).
9. Risks. Situations that present a risk to the beneficiary and others, including past and current
trauma. Barriers relevant to achieving client plan goals, including past or current trauma,
psychosocial factors which may present a risk in decompensation and/or escalation of the client’s
condition (e.g., history of danger to self, danger to others, previous hospitalizations, suicide
attempts, lack of family, prior arrests, prior drug use, history of self-harm [cutting or assaultive
behavior], physical impairments which makes the client vulnerable to others [e.g., wheelchair
bound, visual impairment, deaf).
10. Documentation of the Mental Status Examination.
11. Complete Diagnosis. A diagnosis from the most current CCBHS-MHP Outpatient Included
Diagnosis List. The diagnosis must be consistent with the presenting problems, history, mental
health status exam and/or other clinical data, including any current medical diagnosis.
12. For children and adolescents age 0-20. Child and Adolescent Needs and Strengths (CANS) Core
50 Elements will be incorporated within the current Initial Assessment.
13. Additional clarifying formulation information, as needed.
The Clinician filling out the Assessment must ensure that all sections are completely and accurately filled
out. Do not leave any sections blank, as these may cause a mandated section to remain unassessed
and may lead to disallowances.
The Assessment is not considered complete without a valid signature and date by the assessing clinician
3.2.1. CHILD AND ADOLESCENT NEEDS AND STRENGTHS (CANS)

The Child and Adolescent Needs and Strengths (CANS) Core 50 Elements will be incorporated within
the current Initial Clinical Assessment and Annual Clinical Assessment for clients age 0-20. This is a
requirement at Initial and Annual Assessment and every 6 months.
3.2.2 DOCUMENTATION OF FUNCTIONAL IMPAIRMENT

The identification of functional impairment through the assessment shall be identified to be considered
eligible for most mental health services, a person's mental illness must "result in functional impairment
that substantially interferes with or limits one or more major life activities."
Activity areas may include feeling, mood, and affect; thinking; family relationships; interpersonal
relationships/social isolation; role/work performance; socio-legal conduct; and self-care/activities of daily
living.
For the Child and Adolescent System of Care, the Functional Impairment ratings are located within the
CANS domains of “Life Functioning” (clients age 6-20) or “Functioning” (clients age 0-5). In order to
qualify for services for this level of care, the child/adolescent must have at least one area of life functioning
that has been substantially impacted by the behaviors and/or symptoms stemming from the diagnosis.
Severity of the impairments are validated with at least one “moderate” (equivalent to a CANS score of
“2”) or one “severe” (equivalent to a CANS score of “3”) rating.
For the Adult System of Care, the Functional Impairments are within the Initial/Annual Assessment and
Re-Assessment forms. The client must have a documented severe impairment in at least one area of life
functioning.
The initial assessment, update assessment, and annual assessment notes should include documentation
supporting the functional impairment.

TIMELINESS OF ASSESSMENTS
The Initial Assessment shall be completed and submitted for review and co-signed (if required) within 60
days of initial opening if new to the county system, or 30 days of initial opening if already to open (multiple
providers) to other clinics/providers.
Clients under the age of 21, CCBHS-MHP requires the completion and submission of the Child and
Adolescent Needs and Strengths (CANS) assessment tool as part of the assessment. CCBHS-MHP
redesigned the clinical assessment for the Children’s System of Care to remove any duplicative
information and reduce the size of the overall assessment. In order to receive service authorization,
each assessment, whether an initial or annual, must be accompanied by a CANS (either imbedded within
the assessment or standalone).
Assessment information must be updated on an annual
basis for clients receiving clinical mental health services
New information may be added
(e.g., therapy and case management). Annual Updates are
to the chart, at any time, by
completing an Update to be completed prior to the end of the Established UR
Assessment or including the Track. For those clients receiving medication-only services,
new material in the next Annual the psychiatric reassessment is required at least once every
Assessment. two years.

CHAPTER 4. TREATMENT PLANNING
4.1. PARTNERSHIP PLAN FOR WELLNESS

Key points when creating the Partnership Plan (Treatment Plan):
1. Provides the focus of treatment
2. Contains Client’s Goals, including their Life Goals
3. Highlights client’s/family’s strengths to achieve their goals
4. Lists Clinical Goal(s) to be accomplished by the treatment
5. Treatment Goals objectives shall have “specific observable, and/or specific quantifiable” as related
to the beneficiary’s mental health needs and functional impairment as a result of the mental health
diagnosis.
6. Identifies the propose type of interventions or modalities to achieve goals – include a detailed
description of intervention or modalities to be provided.
7. Includes the frequency and duration of the intervention(s)/strategies
8. Intervention(s)/strategies are focused and address the identified functional impairment as a result
of mental disorder or emotional disturbance.
9. Intervention(s)/modalities are consistent with client plan goal(s) or treatment objectives
10. Intervention(s)/modalities are consistent with an Included Diagnosis.
11. Must be completed prior to the delivery of planned mental health services
12. Documents the client’s/legal responsible party’s participation in the development of, and agreement
with, the treatment plan
13. Includes the Client/Legal Responsible Party signature
14. Documents that Clients are offered a copy of the plan and whether they accept or decline
The Partnership Plan, which is co-created by the client/family and the provider, outlines the goals,
objectives, interventions and timeframes. The Plan must substantiate ongoing medical necessity by
focusing on diminishing/managing the mental health symptom(s) that lead to functional impairment(s),
and/or the prevention of deterioration that has been identified through the assessment process. The
impairment(s) and/or deterioration to be addressed must be consistent with the diagnosis that is the focus
of treatment. Treatment goals should be consistent with the client’s/family’s goals as well. The plan should

be person-centered and focused on the client’s recovery and wellness issues. The plan must be
individualized, strength-based, and should address cultural and linguistic needs.
The client’s participation and understanding of all elements of the plan is essential for successful
outcomes and is required by state regulations. The only exception is when a person has a legal status
that removes his/her decision-making power, e.g., an LPS Conservatorship.
Translating Client Goals into specific, observable and/or
quantifiable/measurable treatment objectives requires
W&I Code Sec. 5600.2. (a) (2) states
considerable skill. Usually what is involved is uncovering
(Persons with mental disabilities) “Are the
concrete issues, behaviors, or barriers that are preventing
central and deciding figure, except where
the client from accomplishing their goal. Following this is a
specifically limited by law, in all planning for
discussion to frame the issue/barrier in a way that is
treatment and rehabilitation based on their
acceptable to the client but is also meaningful in terms of
individual needs. Planning should also include
focusing services. These discussions can all be claimed as
family members and friends as a source of
Plan Development. An ideal clinical treatment goal is one
information and support.”
that that meets both the client’s needs in working towards
the goal and is specific and measurable enough to be able
to chart progress.
Providing services prior to the establishment of Medical Necessity (completion of the Assessment and
Partnership Plan):
To ensure that services are focused on creating goals and strategies in the Partnership Plan, the services
that may be provided prior to the Plan’s completion are limited to doing a thorough assessment and
developing the plan. In other words, until the plan is finalized, only Assessment (331), Plan Development
(315), Crisis Intervention (371), Med/Eval/Rx (361), Med Plan Development (364) can be used for Medi-
Cal claiming.
Unplanned Services allowed for claiming

prior to provision of Assessment and Planned Services allowed after provision of
Treatment Plan Assessment and Treatment Plan
Assessment (331) Rehab Support (317)
Plan Development (315) Individual Therapy (341)
Crisis Intervention (371) Group Rehabilitation (355)
Crisis Stabilization (PES) Group Therapy (351)
Med/Eval/Rx (361) – Only for assessment IHBS (358)
purposes and urgent conditions
Med Plan Development (364) TBS
Case Management Services (541, 561, 571)
ICC (364)
ICC – CFT (365)
Medication Services (361, 362, 363, 369)
Adult Residential Services
Day Treatment Services
Crisis Residential Services
Adult Residential Services
4.1.1. CLIENT PARTICIPATION/AGREEMENT AND SIGNATURES

1. Client participation and agreement with plan is documented by obtaining the signature of the client/
parent/ legal responsible party on the Partnership Plan. The following signatures should be
present and dated:
a. Signature or electronic equivalent of the service provider completing the Plan;
b. Client, or Legal Responsible Party if the client is under the age of 12 or is a conserved adult.
i) Contra Costa County does not recognize the foster parent as the “legal responsible
party” unless court documents are provided clearly stating that the foster parent has
been granted the ability to sign for mental health treatment.
c. A minor can legally sign their Plan if they are at least 12 years old.
i) It is encouraged that a parent/legal responsible party, i.e., CFS worker, conservator,
etc. signature be obtained whenever possible.
d. A co-signature of a Licensed Practitioner of the Healing Arts (LPHA) is needed when the staff
member completing the Partnership Plan is required per CCBHS-MHP Guidelines for Scope
of Practice.
e. Signature of providers of all disciplines providing the service(s), or representing the team, or
program providing the service(s), or person representing CCBHS-MHP providing the
service(s). This includes Psychiatrist & Psychiatric Nurse Practitioner for medication services.
f. Signature of the County Authorizing Committee Member once Plan has been approved for
services.
2. If a client or parent/legal responsible party refuses to sign or is unavailable to sign, the provider
must document on the Partnership Plan the reason why the client or parent/legal responsible
party’s signature was not obtained in a timely manner. Continued attempts to get the client’s/legal
responsible party’s signature are required. Mental health providers shall document these attempts
in the Partnership Plan itself.
a. If the client refuses to sign the document, the date the client refused to sign shall be used for
the signature date and, along with the documentation of signature attempts, will fulfil the
signature requirement.
b. The following signature-related activities should be documented.
i) Phone contact(s) or letters filed in chart with the corresponding Progress Notes.
ii) Discussions between client/family and provider when the provider discusses the Plan
goals over the phone and the parent/legal responsible party/client accepts/agrees to
the Plan goals.
iii) When a copy of the Plan is mailed/faxed to parent/legal responsible party for a
signature along with any followup until the signed copy is received and filed.

c. The service provider is required to offer a copy of the signed Partnership Plan to the
client/legal responsible party. The service provider needs to indicate on the plan whether a
copy of the plan was accepted or declined.
4.1.2. TIMELINESS OF PARTNERSHIP PLANS

The Initial Partnership Plan must be completed within sixty (60) days of the admission date for both Adult
and Children’s System of Care providers in which the client is not receiving any other services within the
county. For clients who have an active admission/services with another county provider, a Partnership
Plan must be completed within thirty (30) days of the admission to the additional program.
The client’s participation and agreement with the treatment plan (obtaining the client/legal responsible
party’s signature and date of signature) must be documented and entered into the record within the same
time frame.
Contra Costa Behavioral Health uses a “track system” to monitor
service authorization. Partnership Plans must be reviewed and
revised on an annual UR Track basis. For example, if the ccLink Users
“established UR Track period” is 10/1/2019 – 9/30/2020, the
Annual Partnership Plan must be completed and signatures • Revisions in ccLink
obtained by the last day (end of the month) of the track so that must be created as an
there is no break in service authorization. In this case, the plan Addendum to the
would need to be completed and brought for authorization by original Initial or Annual
9/30/2020. Partnership Plan.
If the authorization expires (i.e., the Partnership Plan was not

completed or submitted for review within the last month of the
track), services provided during the time period in which there is no authorized treatment plans will be
denied, so it is important to avoid lapses in renewals of annual Partnership Plans.
4.1.3. REVISIONS TO THE PLAN

The Partnership Plan may be revised at any time during the UR authorization period and should be
updated any time there is a significant development or change in the focus of treatment (e.g., Client’s
needs were assessed and the service provider believes that the client/family would benefit from attending
weekly family therapy sessions. The Partnership Plan was then revised to include family therapy.)
If this happens mid-year, the existing Partnership Plan may be revised by adding to it the new goals and
strategies, as well as documenting the date of revision to reflect the change in treatment.
If revisions are necessary, the Partnership Plan does not have to be resubmitted for review by the UR
Authorization Committee unless new service modalities not already authorized were added. It is
recommended, however, that the client/legal responsible party be asked to re-sign the revised
Partnership Plan in order to acknowledge the change in treatment.
4.1.4. COMPONENTS OF THE PARTNERSHIP PLAN

The Partnership Plan contains the following components, which reflect the elements and processes which
fulfill the regulatory requirements as well as facilitate sound clinical practice.
• Strengths
• Other Services/Agencies involved
• Life Goals
• Clinical Treatment Goals
• Strategies to Achieve Goals
• Treatment Modalities
• Revisions, if any
• Proposed Duration
• All Required Signatures
• Indication that a copy of the plan was offered
• If applicable, documentation of the reason why client/legally responsible party signature missing
4.1.5. PARTNERSHIP PLAN PROCESS ELEMENTS

The overall process of creating the Partnership Plan is outlined below and is followed by sub-sections
with more specific details and examples for each component of the process. When creating a Partnership
Plan, the service provider will:
• Include information gathered from the assessment, CANS and the client and/or family, to establish
treatment goals.
• Consider what strengths the client and/or family brings to treatment that could help achieve the
goals.
• Discuss with the client and/or family any potential obstacles that could prevent his/her
achievement of the goals.
• Formulate specific clinical goals and strategies to decrease identified impairments (an important
areas of life functioning as identified in the Assessment/CANS) and their impact primarily through
decreasing mental health symptoms . Collaborate with the client and/or family so that they are
agreeable to the client and/or family, formulate clinical direction, and satisfy CCBHS-MHP
requirements.
• Confirm client/and or legal responsible party signature and client copy are all addressed.
• Obtain co-signature of Licensed Supervisor and/or Medical Doctor as appropriate.
• Submit for review by the Authorization Committee.
4.4. COMPONENT DETAILS AND EXAMPLES

4.4.1. PARTNERSHIP PLAN DATES
The Partnership Plan should be completed and/or signed by all required parties within the initial sixty
(60)-day authorization period or within thirty (30) days from the date any additional service providers
creates a new admission. The date a Partnership Plan becomes valid is determined by the signature date
of the client/legal responsible party or the date of the documentation of why the signature was not

obtained. If the Partnership Plan was not completed and/or signed within the initial authorization period,
a lapse in service authorization will occur and continue until all elements are completed and/or required
signatures obtained.
For example:
1. If the admission date was 1/23/2019, the Initial Partnership Plan is due within sixty (60) days, which
is 3/22/2019. As long as the client is not receiving services from any other service provider outside
of their reporting unit, the UR Track would be 1/2019 - 12/2019.
2. The Partnership Plan must be completed and signed by the service provider and client/legal
responsible party and submitted to the authorization
committee by 3/22/2019. If the client/legally
responsible party was unable to sign the plan by
3/22/2019, then on the bottom of the plan, the service
provider must document why this was not obtained
• The service provider
prior submission to the authorization committee.
completing the plan with
3. The Partnership Plan must be rewritten annually. In the client/family must
general, the annual requirement is determined by the complete the box
established UR track. If the UR Track was 1/2019 –
indicating the client’s
12/2019, the Partnership Plan must be completed by
strengths
the end of the track, which is December 31, 2019 in
order for there not to be a lapse in authorization. • Remember, ALL
NOTE: The Partnership Plan can be approved for a clients have strengths!
maximum of twelve (12) months.
• Do NOT leave this blank
4.4.2. CLIENT STRENGTHS or write “N/A” or “None”.
What to do if they
Strengths are qualities that the client brings to treatment that
help increase the likelihood of achievement of goals. Client
strengths are internal and external factors that should be
identified and emphasized as helpful to the treatment
say “I have no
process.
strengths”.
Examples are:
• If they’re in your office
• Community supports, family/relationships, work, etc.
May be unique to racial, ethnic, and cultural talking about treatment,
(including lesbian, gay, bisexual and transgender) then use “willing to seek
communities treatment”.
• Client’s/Family’s best qualities
• If they were brought by
• Strategies already utilized to help (what worked in
friends/family, then use
the past)
• Competencies/accomplishments interests and
“client has support”.
activities (i.e., sports, art) identified by the consumer
and/or the provider

• Motivation to change
• Employed/engaged in volunteer work
A goal should be stated in the
• Has skills/competencies: vocational, relational, client’s and/or family’s own
transportation savvy, activities of daily living words.
• Intelligent, artistic, musical, good at sports
For example:
• Has knowledge of his/her illness
• Values medication as a recovery tool “I want a job.”
• Has a spiritual program/connected to a church “I want to go back to school to
• Good physical health get a degree.”
• Adaptive coping skills/ help seeking behaviors “I want to be less depressed.”
• Capable of independent living “I want a girlfriend/boyfriend.”

“I want to live in an apartment
When considering strengths, it is beneficial to explore different by myself.”
areas. Examples may be an individual’s most significant or most “I want to get off of SSI and be
valued accomplishment, what motivates them, educational self-sufficient.”
achievements, ways of relaxing and having fun, ways of calming “I want my kids back!”
down when upset, preferred living environment, personal heroes, “I want to be a movie star.”
most meaningful compliment ever received, etc. “I want to be normal.”
It is important to take the time to acknowledge the value of the
individual’s existing relationships and connections. If it is the individual’s preference, significant effort
should be made to include these “natural supports” and unpaid participants, as they often have critical
input and support to offer to the treatment team. Treatment should complement, not interfere with, what
people are already doing to keep themselves well, e.g., drawing support from friends and loved ones.
Strengths should be utilized in every part of the treatment process.
• Strengths identified in the assessment process
• Set objectives to build on strengths in the Partnership Plan
• The progress notes help us show how our interventions help build up the strengths that help
individuals thrive.
4.4.3. LIFE GOALS

The client’s Life Goals are located at the beginning of the Plan and it is intended to be a space where the
client’s goals are freely stated. The Life Goal identified what the client or family hopes to achieve or work
toward. The service provider should use the person’s own words. This may include the person’s hopes
and dreams, as appropriate.
Life Goals are:
• Ideally expressed in the words of the individual, their family and/or other supportive individuals.
• Easily understandable in the client’s preferred language.
• Appropriate to the person’s culture; reflects values, traditions, identity, etc.
• Written in positive terms.
• Consistent with abilities/strengths, preferences and needs.

• Embody hope/alternative to current circumstances.
The focus could be on a short-term goal (within one year) or a long-

term goal (over one year). The service provider can discuss the Formulating a Treatment Goal:
desired life goals with the client to break them down into more ➢ Jessica is a 15 year old girl
realistic steps to create meaningful treatment goals. ➢ Jessica and her parents came to
the county for help with her anger
4.4.4. CLINICAL TREATMENT GOALS issues
➢ Jessica fights with her parents and
The treatment goal is to assist the client and family to identify areas does not like to follow rules
of their life in which an improvement in functioning is desired. ➢ She frequently yells to get what she
wants
Clinical Treatment Goals must be “specific observable” and/or ➢ She pushes her younger siblings
“specific quantifiable/measurable” and stated in terms of the specific when she becomes angry at her
impairment identified in the Assessment, diagnosis and clinical parents
formulation of Medical Necessity. ➢ She reports she is jealous of her
younger siblings and feels like her
They should be related to specific life functioning areas such as living
parents favor them
situation, activities of daily living, school, work, social support, legal ➢ Her parents are fearful that she will
issues, safety physical health, substance abuse and psychiatric hurt someone when she is upset
symptoms.
Goal = Subject (client) + Action
Characteristics of Treatment Goals: Word + symptom+ functional
impairment + Measurement
• Incremental achievements on the path toward reaching a Life
Goal Goal:
• Specific enough to achieve a high degree of inter-provider ✓ Subject (client): Jessica
understanding ✓ Action Word: verbalize her anger
symptom: rather than physical
• Achievable in a timeframe that is realistic and meaningful to assault when functional impairment:
the client family and social functioning
• Clear enough that the client can effectively direct effort toward ✓ Measurement: by
their achievement
• Appropriate to the setting/level of need/stage of change “Jessica will decrease angry
• Appropriate for the person’s age, development and culture outbursts (which impair family
• Observable and/or measurable and quantifiable and social functioning) from 3
• Time limited times per week to 1 time per
week. Reported by parents.”
What does “specific observable” and/or “specific quantifiable/
measurable” mean?
“Specific observable and/or specific quantifiable/measurable” means that the mental health
behavior/symptom exhibited is characterized by the beneficiary measure of duration, frequency, and/or
intensity. A Likert Scale is fine to use (on a scale of 1 to 10). These shall include a baseline (current
number) and goal number. Specific, observable and/or “Specific quantifiable/measurable” requires, first,
that the symptom be specific - for a diagnosis like major depressive disorder, “depression” in and of itself
does not suffice. You need to write specific symptoms, such as refusing to get out of the house, sleeping

all day, poor concentration in class. The second part is who will be doing the observing, be it the client,
clinician, caregivers, or others.
Note: Not every goal need be a symptom-reduction goal. It is permissible for goals to be the development
of skills, but must, in any case, recognize the functional impairment meant to be ameliorated. For
example, “Client will be able get out of the house in order improve her mood and to get along with others
and have friends at least 2-3x/week.” The service provider can elect to use percentages when creating a
treatment goal, however, they must give a baseline so that an auditor can determine success towards
goals.
When?
If treatment goals are meant to be met in less than 12 months or for the remained of the track, please
indicate the time frame. Shorter, interim goals in the service of a longer-term goal can be helpful.
Refer to Chapter 11, Wording Samples, for sample treatment plan goals.
4.4.5. STRATEGIES TO ACHIEVE GOALS

The Strategies section on the Partnership Plan defines the concrete strategies and techniques the service
provider proposes to utilize to facilitate the client’s progress of the clinical treatment goals. These
strategies are behavioral health interventions and address the impairment(s) identified in the
Assessment. They are best stated using the five W’s:
→ Who: Clinical discipline of practitioner (e.g., Therapist, case manager)
→ What: Modality and service provided
→ When: Frequency/intensity/duration
→ Where: Location (if not at the office)
→ Why: Purpose/intent/impact to address a specific mental health impairment
This section should define concrete strategies/actions that will be utilized to assist the client/family to
meet the identified clinical treatment goals. They should depict what the provider intends to actually do.
There may be multiple strategies (different service types) for the same clinical treatment goal. Service
types may include medication services, group therapy, individual therapy, case management brokerage,
and for the full-service partnership clients, intensive case management. Each of the strategies needs to
be specific/provide description of service modality (e.g., Individual therapy using DBT, CBT, motivational
interviewing, and CBSST) and include frequency of service (e.g., 1x/week, 4-6x/month). Be sure to allow
for a range of frequency in the event your frequency often varies. This is especially true for case managed
clients who, at times, may require more intensive care. Non-specific frequency such as “as needed”
and/or “ad hoc” do not meet documentation requirements. Case management strategies usually are
expressed as in the service of the development of independent living skills, and not on symptoms per se.
Examples of Strategies include:
• Therapist will provide individual therapy weekly for the next 12 months and use CBT (e.g., learning
to replace harmful thoughts with helpful ones) to improve mood and self-worth.

• Therapist will provide mindfulness techniques (including breathing, sensate awareness, and
improving concentration) in weekly group therapy sessions for the next three months at the clinic
to reduce anxiety.
• Provider will support client to express unresolved grief to reduce symptoms of depression in
weekly individual sessions for the next 12 months.
• Over the next six months, case manager will meet with the client—primarily in the field--one to six
times per week to teach, model, and implement skills (social and adult living skills) necessary to
help maintain housing.
• Mental Health Clinic to provide medication management one to eight times per three months
(appointments, prescriptions, injections, and refills) to decrease anxiety.
• The case manager will collaborate with treatment team, including psychiatrist, psychotherapist,
and/or community support workers one to four times per month to provide continuity of care.
Example of a weak and/or Example of an acceptably Explanation of acceptable

unacceptable documented intervention: documentation:
documentation of a
strategy:
As-needed Case Case Manager will provide In the acceptable strategy
Management case management services the documentation is
twice monthly for the next year specific and will help the
to support the client in client to understand
maintaining current residential intended services.
placement.
Group services for 12 Therapist will facilitate the This intervention has a
months depression group weekly for specific group and duration.
the next 12 months to help It also documents medical
reduce her feelings of isolation. necessity regarding the
client’s symptoms of
isolation.
Medication support Psychiatrist and nurses will These are specific and
provide medication clear. The client could read
management services these interventions and
(prescriptions, refills, and know why medication
shots) 1-8 times every 3 support may help them.
months to manage impulsivity
and anxiety.
4.4.6. TREATMENT OPTIONS (FORMERLY KNOWN AS SERVICE MODALITIES)

Treatment Options must be indicated on the Partnership Plan. Their focus must be consistent with the
mental health goals and strategies identified on the plan.
CCBHS-MHP Treatment Options Include:

• Individual Therapy
• Family Therapy/Collateral
• Medication Services
• Case Management
• Group Therapy
• Rehab Services
• Day Treatment
• TBS Services (Must be documented if a referral for TBS services is needed)
• WRAP
• Child Wraparound
• Other: ICC
• Other: IHBS
Note: Any mental health service modalities that are not documented on the plan
are not authorized and therefore should not be provided. If a service modality
needs to be added, then this would need to be documented in an addended plan
or on the back of the Partnership Plan.
See Sample Partnership Plans in Chapter 11.5.
4.4.7. DOCUMENTING LANGUAGE ON THE PARTNERSHIP PLAN

Accommodation must be made for non-English-speaking clients/families to ensure the partnership plan
was developed in a manner that was understood and agreed upon by the client/families. The partnership
plan for monolingual client/families must be submitted in the one of the following ways:
• Two partnership plans – one plan written in the client’s primary language and one plan written in
English
• One partnership plan written in the client’s primary language with the English translation listed
below
• One partnership plan written in English, but has a corresponding progress note indicating that the
Service Provider completing the plan conducted the planning session in the Client’s/Family’s
primary language; OR the progress note indicates that an interpreter was used

CHAPTER 5. UTILIZATION REVIEW TRACK
CCBHS-MHP created the Utilization Review (UR) Track system in order to maintain the timeliness of
Assessments and Partnership Plans (CCBHS-MHP, Policy 706, Utilization Review: Specialty Mental
Health Service Authorization Process).
CCBHS-MHP defines a long-term client as Contra Costa Beneficiaries receiving specialty mental health
services, other than crisis intervention, for 60 days or more.
5.1. ESTABLISHMENT OF THE UR TRACK/ TIMEFRAMES FOR

SUBMISSION OF DOCUMENTATION FOR INITIAL SERVICE
AUTHORIZATION
New Admission (new client with no active admissions):
The admission date will establish when initial paperwork will need to be completed. If this is a new client
(currently not receiving any services), the service provider will have sixty (60) days from the admission
date to complete their documents for service authorization. The admission date in turn establishes the
annual UR track.
Example:
Admission Date: 2/10/2019
Initial Paperwork due: 4/9/2019
UR Track Will be: 2/10/2019 – 1/31/2020
Annual paperwork due: 1/2020 (all paperwork must be started/completed and submitted for review
by end of month)
Required Documents for initial service authorization include:
• Completed Assessment with a valid Included diagnosis. See Appendix B.
• Medical Necessity Criteria Form (Children’s Services Only)
• CANS (beneficiaries 0-20 years)
• PSC-35 (beneficiaries 3-18 years)
• Partnership Plan with all required signatures
• LOCUS (beneficiaries in the adult system of care for whom an ANSA has not been completed)
Additional Admissions (established Client/ has at least one active admission):
If the client is receiving services from other service providers/agencies within CCBHS-MHP, the new
(add-on) service provider will have thirty (30) days from the admission date to complete their documents
for service authorization. The UR track has already been established and the new service provider will
need to adhere to the annual UR track and complete all paperwork on the current timeline. In the event

services are being transferred from one clinic to another and the client is still open on the original track,
it is recommended the new provider complete an initial assessment.
Example:
Admission Date: 9/15/2019
Initial Paperwork due: 10/14/2019
Current UR Track: 2/10/19 – 1/31/2020 (already established by initial admission)
Annual paperwork due: 1/2020 (all paperwork must be started/completed and submitted for
review by end of month)
Required Documents for additional initial service provider’s authorization include:

• Partnership Plan with all required signatures
• Copies of the Initial Assessment/Annual Update, CANS (beneficiaries 0-20 years), Medical
Necessity Form, LOCUS (unless an ANSA was completed) from “other” service provider.
• For county providers, these documents must be scanned into ccLink
NOTE: Assessments are good only for 12 months. Use of another agency’s assessment may result in a
partial authorization.
5.2. ANNUAL RENEWAL OF SERVICES

On an annual basis, a reevaluation of the individual’s status and needs must be completed in order to
obtain continued authorization for services. It is good practice to review the risks and benefits of the
services with the individual as often as clinically relevant.
During the last month of the UR Track, each service provider (FACility/PROGram) is responsible for the
completion of their program-specific Partnership Plan and should coordinate with all active service
providers to ensure that all goals and strategies are both covered and differentiated by provider. That is,
if therapy and case management are done by different providers, it is permissible for just one plan to be
written that belongs to the same FAC/PROG, but the goals and strategies of each should be present and
differentiated. If they write two separate plans, there again they need to differentiate services provided to
prevent overlap.
Each provider (FAC/PROG) is responsible for either the completion of the following forms or obtaining
copies of the following forms:
• Completed Annual Update, with a valid/included DSM-5 diagnosis corresponding ICD-10 Code
and DSM-5 code narrative
• CANS (beneficiaries 0-20 years)
• CSI Periodic Form
• LOCUS (beneficiaries over age of 19 for whom an ANSA was not completed)

CHAPTER 6. PROGRESS NOTES
Regardless of which service provider completes the forms, all forms

must have been completed and submitted to UR during the last month
of the authorization. If client signature was unable to be attained, a
statement explaining why should be added at the bottom of the plan
Important: “Cut and submitted to UR. The provider
and Paste” notes should continue to make attempts REMEMBER
occur when a and document such attempts on Progress Notes
progress note progress notes. are
(individual, group,
Progress notes are used to record Legal Documents!
etc.) is worded
the services that result in claims
exactly like or (billing). Please remember that when clinical staff complete a progress
similar to previous note, a claim to the state is submitted; therefore, all progress notes
entries in the must be accurate and factual. Errors in documentation (e.g., using an
record, which is incorrect location or procedure code) directly affect the ability of
considered a CCBHS-MHP to submit accurate claims. This is an aspect of
misrepresentation compliance, and compliance is the personal responsibility of all clinical
of the medical and administrative staff.
necessity
What makes a good progress note? A good progress note accurately
requirement for
represents the services provided. Each progress note needs to justify
coverage of
the service provided. Every billable service must be medically
services. State of
necessary. Medical Necessity is established by ensuring that
California
interventions meet the following two criteria:
considers this
FRAUD! 1. The focus of the proposed intervention is to address the mental
health symptoms identified in association with an “included
diagnosis”, and
2. It is expected the proposed intervention will benefit the consumer
by significantly diminishing the impairment or preventing significant
deterioration in an important area of life functioning. The proposed intervention(s) should help the
client improve or maintain his/her functioning in an important area(s) of life.
Progress notes are used to inform other clinical staff about the client’s treatment, to document and claim
for services, and to provide a legal record. Progress notes may be read by clients/family members. Use
your judgment about what to include. Aim for clarity and brevity when writing notes. Lengthy narrative
notes are discouraged.
Clear and concise documentation is crucial to client care. Progress notes are used to not only to claim
for services, but also to document the client/family’s course and progress in treatment. Progress notes
should clearly indicate the type of service provided; how the service is medically necessary to address
an identified area of impairment; and the progress (or lack of progress) in treatment.
In order to meet regulatory and compliance standards, Progress Notes:
1. Must be related to the client’s progress in treatment
2. Must provide timely documentation of relevant aspects of client care
3. Must document:
a. Client encounters
b. Date, location, and duration of services
c. Context of services
d. Interventions
e. Clients’ responses to interventions
f. Clinical decisions
g. New assessment information
h. Referrals to community responses
i. Signature and date of the person providing the service, including professional degree,
licensure, or job title
j. If service is provided in a language other than English, document the language used. If an
interpreter is used, include the name of the interpreter in the progress note.
4. Progress notes are the method by which other treatment team members or other reviewers (such
as the State, Federal or contracted reviewers) are able to determine Medical Necessity and level
of care/treatment for the client.
5. Each progress note must have components that show what has been done to help a client reach
their goals.
6. If two clinical staff are providing a service for a client together, each staff person’s role and
interventions need to be clearly documented.
6.1. GENERAL GUIDELINES FOR DOCUMENTING MEDICAL

NECESSITY FOR PROGRESS NOTES
CCBHS-MHP requires that clinical staff use the approved CCBHS-MHP Progress Note form (MHC-017).
A completed Progress Note includes treatment goals addressed, description of Current Situation, focus
of activity, and plan sections.
Treatment Goals Treatment Goals Addressed: In this section (if appropriate), document the
treatment goals that are addressed during the session. If this is a client
without a partnership plan, someone who one might be seen at a clinic as the
officer of the day or in crisis, then it is appropriate to write “not applicable” or
“n/a.”

Description of Reason for Contact: Document clearly the client’s reason for seeking
Current treatment, including condition(s) or complaint(s) presented during session.
Situation/Reason for This needs to document why this service is necessary and is not to be
Contact confused with just a statement of a diagnosis.
• Medically necessary reason for client-related contact. This might be a
response, for example, to increased mental health acuity, problems in
the home or in relationships, problems with housing, or problems
getting to appointments.
• A client’s declared reason for you to provide treatment may not be your
reason, and you need to, at minimum, include your reason.
• If you are to help a client with a service that is at jeopardy of not
meeting medical necessity (such as helping with grocery shopping), be
sure to state clearly why you are necessary above and beyond
providing a taxi service. For example, the client’s anxiety impairs him
from doing so alone.
Your intervention later in the note must reflect this.
• Observation of client’s presentation at time of service, including mental
status notes about, for example, hygiene, speech, mood, and
orientation
• Is progress being made?
• Diagnosis change?
• What are the remaining impairment(s)?
The Intervention: Be sure to use descriptive verbs to describe the staff’s

interventions (what did you do). Did you help the client
cope/adapt/respond/problem solve? Did you teach/model/practice?
Focus of Activity The interventions must document:
(Intervention &
Response) • Staff interventions
• Staff assessments, which should include risk assessments if applicable
Use descriptive verbs (see Examples 11.2) when documenting interventions
to describe services provided.
The Plan: The Plan section outlines clinical assessment-informed treatment

planning (what interventions you might try next), collateral contact, referrals
to be made, follow-up items, homework assignments, treatment meetings to
be convened, and others. Any referrals to community resources and other
agencies when appropriate, and any follow-up appointments may also be
included.
Plan • Are new goals needed?
• Document that the treatment goals remain appropriate or revise as
needed.
• If lack of improvement, obtain a consultation to verify the diagnosis or
consider change in treatment strategy.
• Consider treatment titration and plan for discharge.
• Explain the need for additional treatment due to Medical Necessity.
DON’T FORGET:
Your progress note should Make sure your progress

address clinical note relates to the Remember to fill out ALL
interventions that relate to identified Partnership Plan sections of the note.
mental health symptoms or goals.
functional impairments.
6.2. TIMELINESS OF DOCUMENTATION OF SERVICES

All Progress Notes should be completed within twenty-four (24) business hours after the service was
provided. CCBHS-MHP understands that extenuating circumstances may occur and thus allows service
providers three business days.
When documentation does not occur within the three business day period, the service provider will note
the date of service delivery in the billing section and indicate “late entry” on the progress note.
If documentation is not completed within three business days of service, the service provider may not bill
for documentation time.
Any other documents related to a client (e.g., discharge summaries) must also be filed (if received in
hard-copy form) or simply completed (if they are completed within an electronic health record). State
regulations drive timeliness standards, which are based on the idea that documentation completed in
timely fashion has greater accuracy and makes needed clinical information available for the best care of
the client.
The intent of the five (5) business day documentation policy is to establish a trend of timely
documentation. Timely documentation is not only about compliance with State expectations, but it is also
about ensuring that clinically relevant and accurate information is available for the best care of the client.
6.3. FREQUENCY OF DOCUMENTATION

While it has been noted that for every billing entry there must be a corresponding progress note, there
are specific instances when documentation is not completed for every service contact.

Every Service Contact: Specialty Mental Health Services (Individual Therapy, Group Therapy, etc.)
Medication Support Services
Crisis Intervention
Case Management Services
Therapeutic Behavioral Services (TBS)
Daily Notes: Crisis Stabilization (PES)
Day Treatment Intensive
Weekly Notes: Crisis Residential
Day Treatment Rehab
Adult Residential
Day Treatment Intensive Weekly Summary
6.4. PROGRESS NOTE SERVICE DEFINITION

Title 9 Definition (Title 9 §1810.227):
Mental Health Services” means those individual or group therapies and interventions that
are designed to provide reduction of mental health symptoms and improvement or
maintenance of functioning consistent with the goals of learning, development,
independent living, and enhanced self-sufficiency and that are not provided as a
component of Adult Residential Services, Crisis Residential Treatment Services, Crisis
Intervention, Crisis Stabilization, Day Rehabilitation, or Day Treatment Intensive Services.
Mental Health Service activities may include but are not limited to assessment, plan
development, therapy, rehabilitation and collateral.
6.4.1. ASSESSMENT (331)

The Assessment procedure code (331) is used when documenting the clinical analysis of one’s mental
and behavioral health symptoms along with subsequent functionality. mental and behavioral health
symptoms, functionality. This is predicated upon symptoms and behaviors of past and present in
conjunction with mental status, It is informed by the histories of client’s education/work, relationships,
medical, family and upbringing, substance use, trauma, hospitalization, and risk factors. Information is
often gathered from a variety of sources, including past treatment providers, psychological testing,
spouses, and caregivers. Appraisal of the individual’s functioning in the community, such as living
situation, daily activities, social support systems, and health figure in as well. Assessment services must
be provided by a licensed/license-registered and/or license-waived practitioner consistent with
appropriate scope of practice.

Sample Assessment Note
Focus of Activity: Met with client today to discuss continued need for services. Discussed her current stressors,
symptoms, and general functioning. She indicated that her anxiety symptoms (of being unable to go places
because she continues to be afraid of large crowds) had increased this past month. She also stated that her
mom’s health had declined, and she may have to move in with her. Clinician updated annual assessment
recommended continuing individual therapy and possible referrals for family therapy.
Assessment services may include:

1. Gathering information to gain a complete clinical picture.
2. Interviewing the client and/or significant support person.
3. Administering, scoring and analyzing psychological tests.
4. Formulating a diagnosis. Completing an Initial Clinical Assessment and Annual Clinical
Reassessment.
5. Observing the client in a setting such as milieu or school.
It is not acceptable to simply write a note indicating an assessment was completed on a particular date.
The note needs to include why the assessment is being completed and preliminary findings or
observations of the client’s behaviors during the assessment process. In order to obtain service
authorization, CCBHS-MHP requires a completed adult or children’s assessment on CCBHS-MHP
approved forms.
Assessment notes contain elements which only licensed/registered or waivered staff can perform, such
as assigning diagnoses or performing mental status examinations. Staff should only provide and
document assessment services within their scope of practice. Please refer to the Scope of Practice
(Appendix D).
6.4.2. EVALUATION (313)

Evaluation is an appraisal of the client’s community functioning in several areas, including living situation,
daily activities, social support systems, and health status. This procedure code can be claimed by all
clinical staff. Evaluation services may include:
1. Gathering information from other professionals (i.e., teachers, school counselor, therapist)
2. Reviewing and/or analyzing clinical documents and other relevant documents may be justified as
contributing towards an evaluation of the client’s functioning
3. Observing the client in a setting such as a milieu or school, as indicated for clinical purposes or
gather clinically relevant information.

Note: Evaluation (313) is different from Assessment (331), as it typically does not result in a written
Assessment and does not involve formulating a diagnostic impression or completing a Mental Status
Exam.
6.4.3. PLAN DEVELOPMENT (315)

The Plan Development (315) procedure code is used to document the development of the Partnership
Plan, reviewing the plan with the client, obtaining the client signature on the plan, and/or updating or
revising the Partnership Plan. Plan Development is expected to be provided during the development of
the initial plan and for subsequent plan updates. However, it may be used during other times than the
periodic update cycle, as clinically indicated to modify the plan to make it relevant to the client’s needs.
For example, when the client’s status changes (i.e., significant improvement or deterioration), there may
be a need to update the client plan.
Sample Plan Development Note
Focus of Activity: Met with client to discuss treatment plan and goals. Client presents as anxious and guarded.
He seems to be internally preoccupied but denies auditory hallucinations. The client's anxiety prevents him
from performing daily functions such as hygiene, working, and positive social interactions. Discussed with
client his symptoms and current level of functional impairment. We developed goals and strategies to reduce
symptoms of anxiety and his impairments in his hygiene skills, lack of regular work, and little to no positive
social interactions. Completed Partnership Plan. Client was willing to engage in process. Client agreed to
and signed the Partnership Plan. A copy of the plan was given to the client.
Plan development activities include:

• Development and client approval of Partnership Plan
• Negotiating plan goals with the client
• Verification of medical or service necessity for services listed on the Partnership Plan
• Evaluation and justification for modifying the Partnership Plan
• Updating, revising, renewing the Partnership Plan
Partnership Plans may be developed by non-licensed clinical staff, who can claim for this procedure.
However, Partnership Plans need to be approved by licensed and/or licensed waived staff.
6.4.4. COLLATERAL (311)

The Collateral (311) procedure code is used to document contact with any “significant support person” in
the life of the client with the intent of improving or maintaining the mental health of the client.
Definition of Significant Support Persons (CCR, Title 9, 1810.246.1):

“Significant support person” means persons, in the opinion of the beneficiary or the person
providing services, who have or could have a significant role in the successful outcome of
treatment, including but not limited to the parents or legal guardian of a beneficiary who is
a minor, the legal representative of a beneficiary who is not a minor, a person living in the
same household as the beneficiary, the beneficiary's spouse, and relatives of the
beneficiary.
Note: “Significant support persons” do not include speaking with other professionals, paraprofessionals,
physicians, etc. who are involved in the client’s care. If these contacts are relevant to the mental health
treatment and goals of the client, it would be best to bill these services as Case Management Plan
Development or Case Management Linkage.
Sample Collateral Note
Focus of Activity: Clinician received a phone call from client’s grandmother. Clinician listened and provided
emotional support to grandmother while she explained that client’s angry outbursts had increased this past week
at home. Discussed strategies for handling situations when client is angry. Introduced de-escalation techniques
that will assist grandmother in controlling client's behavior at home. Grandmother agreed to try the strategies and
will check in next week on progress with treatment.
Collateral may include helping significant support persons understand and accept the client’s
challenges/barriers and involving them in planning and provision of care. Remember, there must be a
current release of information in the chart to include these supports. These services must be included in
the client’s treatment plan to support the client’s recovery. This procedure code can be claimed by all
clinical staff, however, if providing Family Therapy clinical staff must operate within their scope of practice
(see Appendix D)
Collateral may include, but is not limited to:
• Consultation and training of the significant support person to assist in better utilization of
behavioral health services by the client.
• Consultation and training of the significant support person to assist in better understanding of the
client’s serious emotional disturbance (e.g., psychoeducation).
• The client may or may not be present.
COLLATERAL PROGRESS NOTES:

• List people involved in the services and their role
• Training/Counseling (Family Therapy) provided to the Significant Support Person
• Describe how the client's behavioral health goals were addressed through the collateral support.
• Document the collateral support person’s response to the interventions.
• Follow-Up Plan (if needed).

CLAIMING FOR FAMILY THERAPY
• In family therapy, the family is brought into the treatment process. The emphasis is on the client’s
care, but therapy is aimed at the environment in which the client lives and the interactions of the
family.
• Family members are defined as:
o Immediate family; husband, wife, spouse, sibling(s), child(ren), grandchild(ren),
grandparent(s), mother, father
o Includes live-in companions and significant others
• Primary caregivers who provide care on a voluntary, uncompensated, regular, sustained basis,
guardian, or health care proxy
• A family therapy session does not have to include the client in the session, but documentation
needs to state how the session is medically necessary for the client’s mental health treatment
6.4.5. REHABILITATION (317)

This procedure code is used to document services that assist the client in improving a skill, the
development of a new skill set, or maintaining current functional skills. Rehabilitation service activities
includes assistance in restoring, improving, and/or preserving a client’s functional, social, communication,
or daily living skills to enhance self-sufficiency or self-regulation in multiple life domains relevant to the
developmental age and needs of the client. This procedure code may be claimed by all clinical staff.
Individual Rehabilitation may include:
• Daily living skills, social and leisure skills, grooming and personal hygiene skills, meal preparation
skills, and/or medication compliance (within scope of practice).
• Providing psychosocial education aimed at helping achieve the individual’s goals.
• Education around medication, such as understanding benefits of medication (within scope of
Practice).
6.4.6. INDIVIDUAL THERAPY (341)

Individual Therapy is a service activity which includes a therapeutic intervention that focuses primarily on
symptom reduction as a means to improve functional impairments. Therapeutic interventions can include
the application of strategies incorporating the principles of development, wellness, adjustment to
impairment, and recovery and resiliency. Therapy should assist a client in acquiring greater personal,
interpersonal and community functioning or to modify feelings, thought processes, conditions, attitudes
or behaviors. These interventions and techniques are specifically implemented in the context of a
professional clinical relationship.
• Progress notes need to adequately document the therapeutic intervention(s) or therapy activity
that was provided.
• Therapeutic interventions should focus on the reduction of mental health symptoms related to the
client’s diagnosis.

Only Licensed/Registered/Waivered Staff and trainees who have the training and experience necessary
to provide therapy can bill for this procedure code (Scope of Practice Appendix D).
6.4.7. GROUP THERAPY / FAMILY THERAPY / GROUP REHAB / GROUP COLLATERAL

Specialty Mental Health Services may be provided to more than one individual at the same time. One or
more clinicians may provide these services, and the total time for intervention and documentation may
be claimed. Up to two clinicians may be claimed, and a varying amount of time may be claimed for each
clinician.
Group Therapy (351) is a service provided simultaneously to two (2) or more clients with a primary focus
of symptom reduction in order to improve social functioning and reduce interpersonal conflicts. Only
Licensed/Registered/Waivered Staff and trainees who have the training and experience necessary to
provide therapy may bill for this procedure code.
Family Therapy with client present (319) or without client present (320) are services provided
simultaneously to two (2) or more family members and/or caregivers, either with or without the client
present, to stabilize and/or enhance behavioral, cognitive, and/or affective well-being within the family/
caregiver unit to help the client.
Group Rehab (355) is a service provided simultaneously to two (2) or more clients with directed at
improving, restoring, or maintaining functional skills.
Group Collateral (357) is a service provided simultaneously to two (2) or more significant support
persons of multiple clients in a group setting (e.g., First Hope or a parenting class). Focus of group is on
the mental health needs of the client and not the mental health needs of the significant support persons.
Group Notes Should Document:
• The purpose/focus of the group clearly stated on each note (can be same for all group
participants).
• Each note should also document the interventions/activities that are provided in the group (can
be the same for all group participants).
• There must also be documentation on each progress note the need for more than 1 staff person
for the group (can be the same for all group participants).
• Document on each note how client/family participated in group and client/family response to group
interventions (this must be client-specific and individualized for each group participant).
• ALWAYS include the total number of clients in group, even if the clients are a mix of Medi-Cal
and non Medi-Cal clients.
• If groups are run by two or more providers, each provider must write a note for every client and
differentiate their own specific role in the group.
Formula for Billing Total Service Time:

Example: Billing for a group of five clients, the group was 1 hour long, and documentation time took 10
minutes for each note.
Each staff will bill:

Number of clients (5) x documentation time (10) + 60 minutes (service time) = 1 hour 50 minutes
6.4.8. MEDICATION SUPPORT SERVICES

This service is used exclusively by medical staff where it is within their scope of practice to provide such
services. This service type may include: providing detailed information about how medications work;
different types of medications available and why they are used; anticipated outcomes of taking a
NOTE:
Sample Group Rehab Note The maximum
amount claimable to
Medi-Cal for
Focus of Activity: medication support
services in a 24-
Group Focus: Managing Anger, the focus of this group session is identifying anger triggers and
hourhow to identify
period is 4
signs and symptoms of anger. Staff A provided role modeling of deep breathing exercises andhours
takingper
a personal
client.
“time out”. Staff B provided psychoeducation on healthy ways to set boundaries.
Client was able to identify that he tends to angry at other people when they touch him. He usually grinds his teeth
and sometimes yells. Client practiced deep breathing and agreed to practice next time he starts to grind his teeth
in anger.
medication; the importance of continuing to take a medication even if the symptoms improve or disappear
(as determined clinically appropriate); how the use of the medication may improve the effectiveness of
other services a client is receiving (e.g., group or individual therapy); possible side effects of medications
and how to manage them; information about medication interactions or possible complications related to
using medications with alcohol or other medications or substances; and the impact of choosing to not
take medications. Medication Support Services supports beneficiaries in taking an active role in making
choices about their behavioral health care and helps them make specific, deliberate, and informed
decisions about their treatment options.
Note: Medication support services may only be provided by a Physician, a Registered Nurse, a Licensed
Vocational Nurse, a Psychiatric Technician, a Physician Assistant, a Nurse Practitioner, or a Pharmacist,
acting within their scope of practice.
TYPES OF MEDICATION SERVICES
EVALUATION/RX (361)
Initial Assessment including medical and psychiatric history, current medication, chart review.
Observation of need for medication due to acuity. Consultation with clinician, M.D., or nurse regarding
medication. Prescribing, administering, and dispensing medication, lab work, vitals, observation for
clinical effectiveness, side effects and compliance to medication. Obtaining informed consent for
medications.
RN Injection (362)
Specifically for the injection and all that an injection entails under guidelines of administration/evaluation
of medication.
Education (363)
Medication education (including discussing risks, benefits, and alternative with the individual or significant
support persons.)
Plan Development (364)

Plan development related to the delivery of this service and/or to the status of the client’s community
functioning.
Medication Group (369)

Therapeutic interventions with two or more clients with a primary focus on medications.
6.4.9. CASE MANAGEMENT BROKERAGE

Case Management Brokerage, also known as Targeted Case Management (TCM), are services that
assist a client to access needed medical, educational, social, pre-vocational, 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 client access to service; monitoring of
the client’s progress once he/she receives access to services; and development of the plan for accessing
services.
Note: While more than one program may deliver Case Management services, there should be different
clinical roles and documentation of why more than one program is involved.
When Case Management Brokerage services will be provided to support a client to reach program goals,
it must be listed as an intervention on the client treatment plan.
Types of Service Activities:
Linkage and Advocacy (561)

Identification and pursuit of resources including:
• Interagency and intra-agency consultation and communication
• Monitoring service delivery to ensure a client’s access to service and the service delivery system.
• Assisting the client with coordination and/or referrals to other agencies.
Linkage and Advocacy does not refer to consultation. Consultation is a conversation between one
professional and another professional utilizing another professional’s expertise in order to focus on the
needs of the client. This dialogue between service professionals must focus on the client’s treatment
plan. This is a billable service since it facilitates a relationship between all service providers who are
currently providing care for a client.

Non-Billable: Consultation/Supervision is not reimbursable to the state. The focus of the
conversation is on enhancing the clinician’s skills. if A clinician receiving consultation on how to improve
their therapeutic techniques, this is considered supervision and is not billable.
Focus Justify Plan
•Document the •Include the justification •Be sure to document

assistance/intervention and/or need for the any referrals to outside
provided to the client service based on the services/agencies
•Example: accessing mental health •Include the next steps
housing, job search, symptoms/issues needed to assist the
medical services, client, what is the plan?
referrals
Placement Services (541)

Supportive assistance to the client in the assessment, determination of need and securing of adequate
and appropriate living arrangements, including:
• Monitoring of the client’s progress in regard to housing needs.

• Locating and securing an appropriate living environment.
• Locating and securing funding for housing/placement.
• Pre-placement visit(s)
• Negotiation of housing or placement contracts.
• Placement and placement follow-up.
• Accessing services necessary to secure placement.
Plan Development (571)

Discussing a treatment plan (i.e., IEP, Wraparound Plan, TBS), or monitoring a client’s progress towards
treatment goals. Case management plan development is similar to Plan Development but, has an
emphasis on linking, coordinating, or placement. (i.e., focus on education, vocational, medical needs, or
coordination of care).
6.4.10. CRISIS INTERVENTION

Crisis Intervention is an immediate emergency response that is intended to help a client cope with a crisis
(potential danger to self or others, severe reactions that is above the client’s normal baseline).
Examples of Crisis Intervention include services to clients experiencing acute psychological distress,
acute suicidal ideation, or inability to care for themselves (including provision/utilization of food, clothing
and shelter) due to a mental disorder. Service activities may include, but are not limited to Assessment,
collateral and therapy to address the immediate crisis. Crisis Intervention activities are usually face-to-
face or by telephone with the client and/or significant support person(s) may be provided in the office or
in the community.
Crisis Intervention Progress Notes Describe:
• The immediate emergency requiring crisis response
• Interventions utilized to stabilize the crisis
• Safety Plan developed
• The client’s response and the outcomes
• Follow-up plan and recommendations
EXAMPLES OF CRISIS INTERVENTION ACTIVITIES:

• Client in crisis - assessed mental status and current needs related to immediate crisis.
• Danger to self and others – assessed/provided immediate therapeutic responses to stabilize
crisis.
• Gravely disabled client/current danger to self – provided therapeutic responses to stabilize crisis.
• Client was an imminent danger to self/others - was having a severe reaction to current stressors.
Note: Crisis Intervention progress notes may not always link to the client’s treatment plan.
6.5. DISCHARGE SUMMARY

Discharge summaries document the termination and/or transition of services and provide closure for a
service episode and referrals as appropriate. Discharge summary must be documented using the
Discharge Summary Form.
A Discharge Summary must include at a minimum, the following information:
• Discharge Diagnosis (primary DSM5 diagnosis code and Narrative and ICD10 Code)
• Dates of Treatment
• Referral Source (Reason for Admission/Presenting Problem)
• Discharge Medication (if applicable)
• Allergies
• Outcome (Summary of treatment goals/progress made towards goals)
• Post Discharge needs/plans
• Referrals made
To be a billable service (315 or 571), the discharge must be done within five (5) days of last contact or
notification of planned discontinuance of services. The summary should be for documenting decision-
making regarding medical necessity, or to be such that the beneficiary will benefit, e.g.., to ensure
continuity of car. If these requirements are not met, the services should be coded as non-billable (540).

6.6. NON-BILLABLE SERVICES
Some services are not claimable to Medi-Cal. Non-Reimbursable procedures and certain service
locations block the service from being claimed. Unclaimable services may include a wide variety of
services which may be useful and beneficial to the client but are not reimbursable as a Specialty Mental
Health service. Even though these are not claimable, these services should be documented by all staff
working with clients.
The following services are not Medi-Cal reimbursable:
1. Any service after the client is deceased. Includes “collateral” services to family members of
deceased.
2. Preparing documents for court testimony for the purpose of fulfilling a requirement; whereas when
the preparation of documents is directly related and reflects how the intervention impacts the
client’s behavioral health treatment and/or progress in treatment, then the service may be billable.
3. Completing the reports for mandated reporting such as a CPS or APS.
4. No service provided: Missed visit. Waiting for a “no show” or documenting that a client missed an
appointment.
5. Services under 5 minutes.
6. Traveling to a site when no service is provided due to a “no show”. Leaving a note on the door of a
client or leaving a message on an answering machine or with another individual about the missed
visit.
7. Personal care services provided to individuals including grooming, personal hygiene, assisting with
self-administration of medication, and the preparation of meals.
8. Purely clerical activities (faxing, copying, calling to reschedule, appointment, etc.).
9. Recreation or general play.
10. Socialization-generalized social activities which do not provide individualized feedback.
11. Childcare/babysitting.
12. Academic/Educational services, i.e., actually teaching an academic subject such as math or
reading.
13. Vocational services which have, as a purpose, actual work or work training.
14. Multiple Practitioners in Case Conference or meeting: Only practitioners directly contributing
(involved) in the client’s care may claim for their services, and each practitioner’s unique
contribution to the meeting must be clearly noted.
15. Supervision of clinical staff or trainees is not reimbursable because it does not center on client care
(i.e., development of personal insight that may be impacting clinician’s work with the client).
16. Utilization management, peer review, or other quality improvement activities.

17. Interpretation/Translation; however, an intervention in another language may be claimed.
18. Money Management services (i.e., cashing checks, bringing money, buying clothes for the client).
19. Providing transportation ONLY:
a. NOTE: “Travel” is not “Transportation.”
i) Travel involves the provider going from his/her “home office”, to the location where a
service will be provided.
ii) Transportation involves the provider taking the client/family from one location to
another.
iii) If a “behavioral health service” is provided during the time a provider is transporting the
client/family, then the time spent providing the service is not “transportation” and that
portion of service time can be claimed.
Examples of non-billable services versus billable services:
Academic/Educational Situations:
1. Reimbursable: Sitting with the client during class and redirecting client’s focus when client is
unable sit still.
2. Not Reimbursable: Assisting the consumer with his/her homework.
3. Not Reimbursable: Teaching the client how to type.
Recreational Situations:
1. Reimbursable: Assisted client in creating a list of activities which decrease stress/anxiety.
2. Not Reimbursable: Teaching the individual how to lift weights in order to destress.
Vocational Situations:
1. Reimbursable: Assisting the client in learning how to apply for jobs.
2. Not Reimbursable: Visiting the consumer’s job site to teach him/her how to use a cash register.
Travel/Transportation Situations:
1. Reimbursable: Driving to a client’s home to provide a service – travel time is added to the service
time if the client is there and the service is provided.
2. Reimbursable: Providing supportive interaction with a client while accompanying the client from
one place to another in a vehicle. Claimable time is limited to time spent interacting.
3. Not Reimbursable: Taking a client to a doctor’s appointment and not providing any service other
than driving or sitting and waiting with the client.
Money Management/Budgeting Situations:

1. Reimbursable: Assisting the client with budgeting her money at the grocery store so client could
purchase all needed personal care items for the week.
2. Reimbursable: Brought client weekly check and helped teach the client how to budget his/her
money, discussed client’s anxiety levels during this process.
3. Not reimbursable: Dropped off weekly funds to client so she/he could purchase clothes.
6.7. LOCKOUTS AND LIMITATIONS

LOCKOUTS
A “lockout” means that a service activity is not reimbursable to Medi-Cal because the client resides in
and/or receives mental health services in one of the settings listed below. Clinical staff may provide the
service but need to bill the Non-Billable Lockout procedure code (580).
Jail
No service activities are reimbursable if the
Juvenile Hall (not adjudicated)
client resides in one of these settings
Institutes for Mental Disease (IMD) (except for the day of admission and discharge).
Mental Health Rehab Center (MHRC)
Psychiatric Inpatient client resides in one of these settings
(except for the day of admission and discharge).
Exception: Case Management Placement

(541) for placement related services provided 30
days prior to discharge.
Crisis Residential Treatment client resides in one of these settings
(except for the day of admission and discharge).
• Nierika
• Hope House Exception: Medication Support Services (if
within scope of practice) and Case Management
services are billable.

Katie A: ICC Services client resides in one of these settings
• Hospital
• Psychiatric Health Facilities Exception: Can bill for ICC services for
placement related services provided 30 days
• Psychiatric Nursing Facilities prior to discharge.
•
IHBS may be provided to youth placed in a

Katie A: IHBS Services group home or STRTP facility.
IHBS may be provided in the community
• Group Homes / STRTP limitations (homes, schools, recreational settings, etc.)
Limitation: IHBS services are not permitted
during the same hours of the same day as day
treatment, group therapy, TBS, or Targeted
Case Management (TCM).
The maximum amount claimable for Medication
Limits for Medication Support Services Support Services for a client in a 24-hour period
is 4 hours and is based on staff time and is not
program specific.
The maximum amount claimable for Crisis
Limits for Crisis Intervention Intervention in a 24-hour period is 8 hours and is
based on staff time and is not program specific.
Mental Health services are not reimbursable if
Limits for Day Treatment provided by the same Day Treatment staff
during the same time period that Day Treatment
services are being provided.
6.8. SERVICE TYPE COMPARISON

Sometimes the same intervention activity can be described differently, making it look like either one
service type or another.
The following common service activities are matched with the best procedure code.
To Document Use

• Coordinating
• Linking
• Checking on whether s/he has followed through with a
Case Management Linkage
referral
• Relaying information from consumer/therapist/case
manager/psychiatrist to another clinician
• Placement
Case Management Placement
• Discharge planning
• Assisting with a specific problem area

• Assisting a client overcome an obstacle
• Helping strategize with consumer about how they can
accomplish….
• Figuring out what obstacles are
• Educating regarding how symptoms/problem behaviors
are getting in the way Rehab/Group Rehab [317, 355]
• Educating about how symptoms/problem behaviors might
be managed
And the focus is functioning skills (improving, maintaining,

restoring)
• Assisting with a specific problem area

• Showing consumer how some obstacle might be
overcome
• Helping strategize with consumer about how they can
accomplish….
• Figuring out what obstacles are
• Educating regarding how symptoms/problem behaviors Individual/Group [341, 351]
are getting in the way (If within scope of practice.)
• Educating about how symptoms/problem behaviors might
be managed
And the focus is on symptom reduction and stability, with the

goal of improving functioning

• Getting information from a significant support person in a
client’s life
• Discussing (assuming with permission) with a significant
support person in a client’s life how to collaborate in
overcoming obstacles, or how they might support (and Collateral/Group Collateral
not hinder) some area of improvement in functioning. [311, 357]
Note: Do not use collateral for coordinating or collaborating

with other providers - may be linkage, or plan development,
depending on service.
• Gathering information from the client

• Gathering information about the client from another
source
Evaluation [313]
• Analyzing information from sources to make a complete
(and documented) picture of how the client is functioning,
what are obstacles, etc.
• Gathering information from the consumer

• Gathering information about the consumer from another
source
• Analyzing information from sources to make a complete Assessment [331]
picture of how the consumer is functioning, what are (If within scope of practice).
obstacles, etc.
• Do a Mental Status Exam
• Formulate a diagnosis
• Taking information from evaluation/assessment and

developing a written plan.
Plan Development [315]
• Discussing, negotiating, getting approval of a written
plan.
• If doing Plan Development activities, but the goals are

Case Management Plan
limited to linking, placement, and coordination, Checking
development [571]
on progress toward a previously planned goal.
• An immediate response to an acute situation

• An intervention to prevent an escalation that may include
violence or self-destructive behavior or would cause loss Crisis Intervention [371]
of housing
• Facilitating a 5150

• Must serve to diminish the client’s mental health
symptoms and functional impairments
• Creates behavioral, cognitive, and/or affective change in
the group of family / caregivers
• Therapeutic interventions may facilitate one or more of
the following: Family Therapy
o Understanding the client’s mental health With Client Present [319]
symptoms, impairments, and their impact on Without Client Present [320]
family / caregiver group dynamics
o Learning strategies to support the client
o Improving family / caregiver group
communication and conflict
o Developing attachment between the client and
family / caregiver group

Below are a few examples.
Issue Case Management Service Mental Health Services
Assist client in researching job Individual or Rehab: Staff works with client
Client wants
opportunities and helping client practice job to try/develop coping skills to manage
a job
interviews due to extreme anxiety. (561) anxiety when client applies for jobs.
Assist client with resources to low cost food Rehab: Helping the client to develop skills
Rep-payee to make a realistic budget
options. Provided information on Food
or Budget
Banks in the area and filling out forms for Individual: identifying past barriers to
problems
Food Stamps. (561) maintaining budget.
Consulting with education staff regarding Collateral: Working with client and parent to
School
client’s school behavior and any areas of practice behavioral interventions that help
Problems
need. (561 or 571) client to focus while working on homework.
Consulting with care providers regarding Individual: Meeting with client to discuss
client’s changing needs and possible triggers to acting-out behaviors which make
Risk of losing referrals to housing. (541) client’s current placement at risk.
placement Rehab: Assisting in developing
interpersonal skills to increase prosocial
interactions with housemates.
Advocating for client during Social Security Individual: Working with client to identify
Access to appointment in order apply for benefits. how anxiety impacts ability to apply for
treatment (561) benefits.
client needs
help applying Rehab: Help client develop skills around
for benefits time management and focusing in order to
complete application for benefits.

CHAPTER 7. SCOPE OF PRACTICE/COMPETENCE/WORK
Staff must only provide services that are within their scope of practice and scope of competency. Scope
of practice refers to how the law defines what members of a licensed profession may do in their licensed
practice. It applies to the profession as a whole. Scope of competence refers to those practices for which
an individual member of the profession has been adequately trained. Scope of work refers to limitations
imposed by CCBHS-MHP to ensure optimal utilization of staff resources.
Some services are provided under the direction of another licensed practitioner. "Under the direction of"
means that the individual directing service is acting as a Program Supervisor or manager, providing direct
or functional supervision of service delivery, or review, approval and signing client plans. An individual
directing a service is not required to be physically present at the service site to exercise direction. The
licensed professional directing a service assumes ultimate responsibility for the Rehabilitative Mental
Health Service provided. Services are provided under the direction of a physician, a psychologist, a
waivered psychologist, a licensed clinical social worker, a registered licensed clinical social worker, a
registered marriage and family therapist, or a registered nurse (including a certified nurse specialist, or a
nurse practitioner).
A "Waivered Professional” is defined as: A psychologist candidate, an individual employed or under
contract to provide services as a psychologist who is gaining the experience required for licensure and
who has been granted a professional licensing waiver to the extent authorized under State law; or
A “Registered Professional” (AMFT or ASW) is defined as: A marriage and family therapist candidate or
a licensed clinical social worker candidate, who has registered with the corresponding state licensing
authority for marriage and family therapists or clinical social workers to obtain supervised clinical hours
for marriage and family therapist or clinical social worker or professional clinical counselor licensure, to
the extent authorized under state law.
A “Licensed Practitioner of the Healing Arts (LPHA)” is defined as: Any health practitioner who possesses
a valid California clinical licensure in one of the following professional categories:
• Physician/Nurse Practitioner
• Licensed Clinical Psychologist (PhD/PsyD)
• Licensed Clinical Social Worker
• Licensed Marriage and Family Therapist
• Registered Nurse*
Can conduct comprehensive assessments and provide a diagnosis without co-signature (*except for RN
staff, as providing a mental health diagnosis is out of their scope of practice).
A “Clinician/Therapist” is defined as: A mental health care professional that diagnoses, provides
treatment and holds a valid license (MD, NP, MFT, LCSW, PhD/PsyD) or valid internship number (AMFT
or ASW) or has been granted trainee/waivered status.

7.1. CCBHS-MHP PROFESSIONAL CLASSIFICATIONS AND LICENSES
Below are tables containing the most common licenses or professional classifications/designations in the
Behavioral Health field, with brief definitions and characteristics. In conjunction with information and
tables from the preceding sections, these following tables can be used to help further clarify what clinical
activities are within the scope of practice of particular professionals.
AA, Bachelor’s, and/or Accrued Experience

Title Definitions/Characteristics
MHRS (Mental Health Rehabilitation Specialist) • Possesses a bachelor’s degree (BS or BA) in a
mental health related field and a minimum of
four (4) years of experience in a mental health
setting as a specialist in the fields of physical
restoration, social adjustment, or vocational
adjustment.
• Or, an associate arts degree and a minimum of
six (6) years of experience in a mental health
setting.
• Or, graduate education may be substituted for
the experience on a year-for-year basis. For
example, someone with a bachelor’s degree, 2
years of graduate school, and 2 years of
experience in a mental health setting can qualify
to be an MHRS.
Designated Mental Health Worker (DMHW) • Any other direct service staff providing client
support services that does not meet any of the
other specified licensure or classification
definitions or characteristics, i.e., Staff without
BA/BS and 4 years’ experience, or with an AA &
and 6 years’ experience.
Graduate School (pre-Masters or pre-Doctoral)
Psychologist Intern (pre-Doctoral) • Completed academic courses but have not
been awarded their doctoral degree.
• Completing one of the final steps of clinical
training, which is one year of full-time work in a
clinical setting supervised by a licensed
psychologist.
• Intern status requires a formal agreement
between the student’s school and the licensed
psychologist that is providing supervision.

Psychologist Trainee (pre-Doctoral) • In the process of completing a qualifying
doctoral degree.
• Often called “Practicum Students.”
• Receiving academic credit while acquiring
“hands-on” experience in psychology by
working within a variety of community agencies,
institutions, businesses, and industrial settings.
• Supervised by a licensed psychologist.
MSW Trainees • In the process of completing an accredited
Masters of Social Work program.
• Not officially registered with the CA Board of
Behavioral Sciences (BBS); does not have a
BBS registration certificate or number.
• Completing clinical hours as part of their
graduate school internship field placement.
MFT Trainee • In the process of completing a qualifying
doctorate or master’s program.
• Not officially registered with the CA Board of
Behavioral Sciences (BBS); does not have a
BBS registration certificate or number.
• Completing clinical hours as part of their
graduate school trainee practicum course.
Post-Master’s, Pre-License (Interns), Post-Doctorate (Waivered)
ASW (Associate Social Worker) • Completed an accredited Masters of Social
Work (MSW) program.
• In the process of obtaining clinical hours
towards a LCSW license
• Registered with the CA Board of Behavioral
Sciences (BBS) as an ASW
• Possesses a current BBS registration certificate
(which contains a valid BBS registration
number)
AAMFT (Associate Marriage and Family • Completed a qualifying Doctorate or Master’s
Therapist) degree.
• In the process of obtaining clinical hours
towards an MFT license
• Registered with the CA Board of Behavioral
Sciences (BBS) as an IMF (this is the official
BBS title, but it is interchangeable with AAMFT)
• Possesses a current BBS registration certificate
(which contains a valid BBS registration
number)
Psychologist (Waivered) • Issued a waiver by the State of CA Department
of Mental Health to practice psychology in CA.
Possess valid waiver.
• Waiver is limited to 5 years.
Licensed
Psychologist (Licensed) • Licensed by the CA Board of Psychology
• Possesses a current CA Board of Psychology
license certificate (which contains a valid
license number)
LCSW (Licensed Clinical Social Worker) • Licensed by the CA Board of Behavioral
Sciences (BBS)
• Possesses a current BBS license certificate
(which contains a valid BBS license number)
MFT (Licensed Marriage and Family Therapist) • Licensed by the CA Board of Behavioral
Sciences (BBS)
LPCC (Licensed Professional Clinical Counselor) • Licensed by the CA Board of Behavioral
Sciences (BBS)
LPCC with Restricted license • Please see Appendix D for complete
definition.
• Licensed by the CA Board of Behavioral
Sciences (BBS)
• Has not met the required hours to assess
and treat couples and families.
Scope of Practice is defined by Title 9, CCR, Section 1810.227, and further clarified by DMH Letter No.
02-09, The grid above provides an outline but does not authorize individual practitioners to work outside
their own scope of competence.
Some staffing classifications require a co-signature where the clinical supervisor provides clinical
supervision using the co-signature as a supervision tool. State laws and regulations specify that a co-
signature does not enable someone to provide services beyond his/her scope of practice.
Medical
Registered Nurse (RN) Registered with the California Board of Registered
Nursing (BRN)
Clinical Nurse Specialist (CNS/MSN) An RN with a Masters Degree in an area of
specialization and certification by BRN.
Psychiatric /Mental Health Nurse A CNS with a specialization in Psychiatry/Mental
Health, certified by BRN.

Nurse Practitioner (NP) An RN who has completed a Nurse Practitioner
program, certified by BRN.
Licensed Psychiatric Technician (LPT) Licensed by California Board of Vocational Nursing
and Psychiatric Technicians
Physician (MD) Licensed by the Medical Board of California

CHAPTER 9. MEDICATION CONSENTS
9.1. MEDICATION CONSENTS

A Medication Consent must be obtained for every new medication and should be specific to each
medication prescribed. medication consents are and can be valid every two (2) years. A note indicating
discussion about medications and side effects and the accompanying written information/materials
provided to the beneficiary does not replace the signed form. It shall include the documentation of a
discussion about risks of not taking as prescribed, what side effects for client to be aware of, and other
education about risks and benefits of taking or not taking the recommended medication. A parent or
guardian must sign a consent for a minor for psychotropic medications. The MD/NP is also responsible
for providing information to client about the specific medication, preferably in written form, at minimum
verbally. This provision of information should be documented in the note.
Medication Consent Requirements:

1. Consent must be signed/dated by beneficiary agreeing to each prescribed medication.
2. Consent must include the following:
a. Signature and Licensure/Date of Prescriber
b. Reason for taking medication
c. Reasonable for alternative treatments, if any
d. Type of medication
e. Range of frequency
f. Dosage
g. Method of administration
h. Duration of taking the medication
i. Probable side effects
j. Possible side effects, if taken for longer than three months
3. Consents can be withdrawn at any time
NOTE: A JV220 is not considered a complete medication consent until a Medication Consent Form is
completed stating that the therapeutic benefits and side effects have been discussed with the
family/caregiver/provider and signature was obtained.
9.2. MEDICATION DOCUMENTATION GUIDELINES

Client Plan: As with other planned services, Title 9 Regulations require an annual plan and evidence
of client’s participation in the plan.

Assessments: CCBHS-MHP currently requires an Initial Psychiatric Assessment upon episode
opening. Psychiatrist must complete re-assessments every two years, before the second and
subsequent authorization period expires. The completed assessment of a licensed or license-eligible
clinician or Nurse Practitioner with specialty certification in Psychiatry may be substituted for the
psychiatric assessment. (Please refer to CCBHS-MHP Policy and Procedure 706-MH and 709-MH)
Medication Support Services: Medication Support Services include prescribing, administering,
dispensing, and monitoring of psychiatric medications or biologicals that are necessary to alleviate the
symptoms of mental illness.
CAUTION: Physician services that are not psychiatric services are not the responsibility of the MHP.
These would include services that are to address or ameliorate a physical condition that is not related to
a mental health condition. Referral to and collaboration with primary care is encouraged. Services to
ameliorate physical conditions related to psychotropic medications should be documented in a way that
the link to the psychiatric condition is clear.
Time Claiming Limitations for Medication Support: The maximum amount claimable for a client for
Medication Support Services in a 24-Hour period is four (4) hours. Note that time spent by multiple
medication support service staff is combined toward this maximum.

CHAPTER 10. SPECIAL POPULATIONS
10.1. KATIE A. SUBCLASS

As set forth in the Katie A. Settlement Agreement: There are children and youth who have more intensive
needs to receive medically necessary mental health services in their own home, a family setting or the
most homelike setting appropriate to their needs, in order to facilitate reunification and to meet their needs
for safety, permanence and well-being.
In 2016, the provision of Katie A. services was expanded to include all Early and Periodic Screening
Diagnostic and Treatment (EPSDT) eligible children/youth who meet criteria as established in the core
practice model regardless of CFS involvement.
The Katie A. Subclass is a group of children/youth:
• Are full scope Medi-Cal (Title 9) eligible.
• Have an open child welfare services case {means any of the following: a) child is in foster care;
b) child has a voluntary family maintenance case (pre or post, returning home, in foster or relative
placement), including both court ordered and by voluntary agreement. It does not include cases
in which only emergency response referrals are made}; and
• Meet the Medical Necessity criteria for Specialty Mental Health Services (SMHS) as set forth in
CCR, Title 9, Section 1830.205 or section 1830.210
• One of the two items below:
o Currently being considered for: Wraparound, therapeutic foster care, specialized care rate
due to behavioral health needs or other intensive EPSDT services, including but not limited
to therapeutic behavioral services or crisis stabilization/intervention (see definitions listed in
glossary)
o Currently in or being considered for group home (RCL 10 or above), a psychiatric hospital or
24-hour mental health treatment facility (e.g., psychiatric inpatient hospital, community
residential treatment facility); or has experienced three or more placements within 24 months
due to behavioral health needs.
10.1.1. KATIE A. SERVICE PROCEDURES
INTENSIVE CARE COORDINATION (ICC)

Intensive Care Coordination (ICC) is similar to the activities that are routinely provided to our clients as
Case Management. ICC must be delivered using a Child/Youth/Client and Family Team (CFT) to develop
and guide the planning and service delivery process. The difference between this service and traditional

Case Management is that ICC must be used to facilitate implementation of the cross-system/multi-agency
collaborative services approach. ICC also differs from Case Management in that it typically requires more
frequent and active participation by the ICC Coordinator to ensure that the needs of the child/youth are
being met.
INTENSIVE HOME-BASED SERVICES (IHBS)

Intensive Home Based Services (IHBS) are intensive, individualized and strength-based, needs-driven
intervention activities that support the engagement and participation of the Child/Youth/Client and their
significant support persons to help the child/youth develop skills and achieve the goals and objective of
the plan. These are not traditional therapeutic services.
This service differs from rehabilitation services in that it is expected to be of significant intensity to address
the intensive mental health needs of the child/youth and are predominantly delivered outside of the office
setting such as at the client’s home, school or another community location.
10.1.2. KATIE-A RESTRICTIONS FOR ICC & IHBS PROCEDURE

• ICC services are locked out for youth in hospitals, group homes, psychiatric health facilities, or
psychiatric nursing facilities except for the purposes of coordinating placement of the youth
transitioning from those facilities for a maximum of thirty (30) days and for no more than 3 non-
consecutive thirty (30)-day periods.
• IHBS may be provided to youth in a group home facility; IHBS can be provided in the community
(homes, schools, recreational settings, etc.) IHBS services are not permitted during the same
hours of the same day as: day treatment, group therapy, or TBS.
10.2. THERAPEUTIC BEHAVIORAL SERVICES (TBS) CLASS

As stated in the Emily Q Settlement document, children and youth under the age of 21 who, in addition
to having full scope Medi-Cal and meeting Medical Necessity criteria, also meet the class criteria for TBS
if:
• Child/Youth is placed in a group home facility of RCL 12 or above or in a locked treatment facility
for the treatment of mental health needs; or
• Child/Youth is being considered by the county for placement in a facility described above; or
• Child/Youth has undergone at least one emergency psychiatric hospitalization related to his/her
current presenting mental health diagnosis within the preceding 24 months; or
• Child/Youth has previously received TBS while a member of the certified class; or
• Child/Youth is at risk of psychiatric hospitalization.
10.2.1. TBS SERVICES

Therapeutic behavioral service (TBS) is an Early and Periodic Screening, Diagnosis, and Treatment
(EPSDT) supplemental specialty mental health service. TBS is an intensive one-to-one, short-term
outpatient treatment intervention. TBS is used to prevent placement in a group home at Rate
Classification Level (RCL) 12 through 14 or a locked facility, or to enable a transition from any of those
levels to a lower level of residential care.
TBS is intended to supplement other specialty mental health services by addressing the target
behavior(s) or symptom(s) that are jeopardizing the child/youth’s current living situation or planned
transition to a to a lower level of placement. The purpose of providing TBS is to further the child/youth’s
overall treatment goals by providing additional TBS during a short-term period.
10.2.2. TBS SERVICE PROCEDURES

TBS INTERVENTION: A TBS intervention is defined as an individualized one-to-one behavioral
assistance intervention to accomplish outcomes specifically outlined in the written TBS treatment plan.
A TBS intervention can be provided either through face-to-face interaction or by telephone; however, a
significant component of this service activity is having the staff person on-site and immediately available
to intervene for a specified period of time.
TBS COLLATERAL: A TBS collateral service activity is an activity provided to significant support persons
in the child/youth’s life, rather than to the child/youth. The documentation of collateral service activities
must indicate clearly that the overall goal of collateral service activities is to help improve, maintain, and
restore the child/youth’s mental health status through interaction with the significant support person.
TBS ASSESSMENT: A TBS assessment service activity is an activity conducted by a provider to assess
a child/youth’s current problem presentation, maladaptive at-risk behaviors that require TBS, member
class inclusion criteria, and clinical need for TBS services. Periodic re-assessments for continued medical
necessity and clinical need for TBS should also be recorded under this service function.
TBS PLANS: TBS Plans of Care/Client Plan service activities include the preparation and development
of a TBS care plan. Activities that would qualify under this service function code include, but are not
limited to:
• Preparing Client Plans
• Reviewing Client Plan (Reimbursable only if review results in documented modifications to the
Client Plan)
• Updating Client Plan
• Discussion with others to coordinate development of a child/youth’s Client Plan (excludes
supervision). (Reimbursable only if discussion results in documented modifications to the Client
Plan.)

CHAPTER 11. WORDING SAMPLES
11.1. SAMPLE STRENGTHS

Strengths refer to individual and environmental factors that increase the likelihood of success. Therefore,
it is not only important to recognize individual and family strengths, but to use these strengths to help
them reach their full potential and life goals.
• Motivated to change
• Has a support system –friends, family, etc.
• Employed/does volunteer work
• Has skills/competencies: vocational, relational, transportation savvy, activities of daily living
• Intelligent, artistic, musical, good at sports
• Acknowledges mental health diagnosis or symptoms
• Sees value in taking medications
• Has a spiritual program/connected to church
• Good physical health
• Adaptive coping skills
• Capable of independent living
• Interested in restoring relationships
11.2. SAMPLE INTERVENTION WORDS

Analyze Arrange Assess Clarify
Connect Develop Discuss Educate
Encourage Evaluate Explore Facilitate
Identify Interpret List Modelled
Practice Refer Reframe Reinforce
Support Utilize
11.3. SAMPLE INTERVENTION PHRASES FOR SPECIFIC

PSYCHIATRIC SYMPTOMS and CONDITIONS
ANXIETY
• Assess reasons for symptoms of anxiety • Explore triggers/situations
• Refer for medication evaluation to • Discuss benefits of taking medication
address
• Encourage reading on subject of anxiety • Discuss how medication is helping
• Explore benefits/changes in symptoms • Teach relaxation skills
• Utilize relaxation homework to reinforced • Analyze fears, in logical manner
skills learned
• Develop insight into worry/avoidance • Identify source of distorted thoughts
• Encourage use of self-talk exercises • Teach thought stopping techniques
• Identify situations that are anxiety • Teach/practice problem-solving
provoking strategies
• Encourage routine use of strategies • Identify coping skills that have helped in
the past
• Validate/reinforce use of coping skills • Identify unresolved conflicts and how
they play out
BORDERLINE PERSONALITY
• Assess behaviors and thoughts • Explore interpersonal skills
• Explore trauma/abuse • Validate distress and difficulties
• Explore how DBT may be helpful • Encourage outside reading on BPD
• Explore risky behaviors • Explore self-injurious behaviors
• Improve insight into self-injurious • Assess suicidal behaviors
behaviors
• Encourage and practice use of coping • Identify and work through therapy
skills interfering behaviors
• Discuss benefits/effectiveness of • Educate on skills training
medication
• Encourage use of skills training skills • Explore all self-talk
• Reinforce use of positive self-talk • Explore and identify triggers
• Review homework • Review Diary Card
• Reinforce completion of homework/diary • Reinforce use of DBT skills
card
• Encourage/reinforce trust in own
responses
SUBSTANCE USE/ABUSE (impulsivity, poor judgment, mood disorder)

• Explore how mental health symptoms • Refer for physical exam to primary care
lead to drugs/alcohol physician
• Encourage follow up with physician • Support and encourage evaluation for
psychotropic medication
• Discuss benefits/effectiveness of • Encourage participation in appointments
medication with psychiatrist
• List/identify negative consequences of • Educate on consequences of substance
substance use/abuse and establish use on mental health
replacement behavior
• Encourage to remain open to discussion • Refer to inpatient/outpatient program
around denial/acceptance
• Facilitate/explore understanding of risk • List positive aspects of using adaptive
factors replacement behavior (to maintain
sobriety)
• Reinforce development of substance free • Review effects of negative peer
relationships influences
• Encourage exercise and social activities • Encourage positive change in living
that do not include substances situation
• Identify positive aspects of sobriety on • Explore effects of self-talk
family unit/social support system
• Reframe negative self-talk • Assess stress management skills
• Teach stress management skills • Reinforce use of stress management
skills
• Explore effective after-Client Plan
TRAUMA
• Work together on building trust • Explore issues around trust
• Teach/explore trust in others • Research family dynamics and how they
play out
• Explore effects of childhood experiences • Encourage healthy expression of feelings
• Encourage use of journaling • Encourage outside reading on trauma
• Explore how trauma impacts parenting • Educate on dissociation as a coping
patterns response
• Explore history of dissociative • Support confronting of perpetrator
experiences
• Utilize empty-chair exercise to work • Explore/identify benefits of forgiveness
through trauma
• Explore roles of victim and survivor and
how they are playing out
DEPENDENCY
• Explore history of dependency on others • Identify how fear of disappointing others
affects functioning
• List positive aspects of self • Assign positive affirmations
• Identify how distorted thoughts affect • Explore fears of independence
understanding
• Identify ways to increase independence • Teach and reinforce positive self-talk
• Explore effects of sensitivity to criticism • Educate on co-dependency
• Explore issues around co-dependency • Educate on benefits of assertiveness
skills
• Teach/practice assertiveness skills • Reinforce/encourage assertiveness
• Encourage use of “No” • Identify and list steps toward
independence
• Identify ways of giving without receiving • Teach about healthy boundaries
• Practice/reinforce/model use of healthy • Encourage decision making
boundaries
DEPRESSION
• Assess history of depressed mood • Identify symptoms of depression
• Identify what behaviors associated with • Explore/assess level of risk
depression
• Assess/monitor suicide potential and risk • Teach and identify coping skills to
decrease suicide risks
• Identify patterns of depression • Encourage journaling feelings as coping
skill
• Identify support system • Develop WRAP plan
• Encourage use of WRAP plan • Encourage/reinforce positive self-talk
• Explore issues of unresolved grief/loss • Teach/identify coping skills to manage
interpersonal problems
• Reinforce/recommend physical activity • Monitor and encourage self-care
(hygiene/grooming)
• Normalize feelings of sadness and • Explore potential reasons for
responses sadness/pain
• Connect anger/guilt with depression
FAMILY CONFLICT
• Explore patterns of conflict within the • Teach conflict resolution
family
• Explore familial communication patterns • Facilitate family communication
• Identify how family patterns of conflict • Facilitate healthy expression of
and communication are played out feelings/concerns
• Reinforce use of healthy expression of • Identify/reinforce family strengths
feelings
• List ways family may participate in • Define roles in the family
healthy activities in community
• Identify areas of strength that may be • Teach/practice/model parenting
used to parent techniques
• Identify patterns of dependency on • Identify feelings of
family members fear/guilt/disappointment
• Explore/identify patterns of dependency
within family unit
BIPOLAR DISORDER
• Explore symptoms concerning bipolar • Educate on mania and depression
disorder
• Use reflection to identify • Educate on risky behaviors associated
mania/depression behaviors with mania
• Explore behaviors associated with mania • Identify coping skills
• Identify early warning signs and energy • Explore grandiosity
levels
• Encourage/discuss effectiveness of • Encourage participation in appointments
medication with psychiatrist
• Identify effects of stress on psychiatric • Identify/discuss issues of impulsivity
symptoms
• Discuss consequences of impulsivity • Model/reinforce effective communication
• Utilize cognitive reframe • Encourage education on bipolar disorder
MEDICAL ISSUES
• Gather information regarding medical • Identify who is primary care physician
history
• Encourage follow through with medical • Identify/explore negative consequences
recommendations of no following through
• Educate on grief/loss issues and impact • Explore denial around recommended
on openness to medical treatment medical treatment/follow up
• Process feelings of • Normalize feelings of
fear/ambivalence/anxiety fear/ambivalence/anxiety
• Teach relaxation exercises • Monitor/encourage compliance with
medical recommendations
• Reinforce use of coping skills during • Reinforce communication skills to ask for
medical appointments clarity
• Reinforce assertiveness skills • Encourage use of social support system
11.4. SAMPLE PROGRESS NOTES

Format for each sample: 1. Current Situation, 2. Focus Activity, 3. Plan
SAMPLE ASSESSMENT (331)

1. Client came in to update annual assessment.
2. Met with client today to discuss continued need for services. Discussed her current stressors,
symptoms, and general functioning. She indicated that her anxiety symptoms of being unable to
go places because she continues to be afraid of large crowds had been increased this past month.
She also stated that her mom’s health had declined, and she may have to move in with her.
3. Clinician updated annual assessment recommended continuing individual therapy and possible
referrals for family therapy.
SAMPLE EVALUATION (313)

1. Met with Client and family to gather information for the 6-month CANS update.
2. Met at client’s home and spoke with parents to discuss the CANS Assessment update. This
clinician reviewed the client’s current level of functioning at home and school. Identified progress
in treatment and current service needs. Please see attached CANS Assessment update.
3. Clinician will continue to provide Individual Therapy, Family Therapy, and as needed Case
Management. Will review CANS scores and update Treatment Plan if necessary.
SAMPLE PLAN DEVELOPMENT (315)

1. Met with Client to discuss treatment plan goals.
2. Client presents as anxious and guarded. He seems to be internally preoccupied but denies auditory
hallucinations. The client's anxiety prevents him from performing daily functions such as hygiene,
working, and positive social interactions. Discussed with client his symptoms and current level of
functional impairment. We developed goals and strategies to reduce symptoms of anxiety and his
impairments in his hygiene skills, lack of regular work, and little to no positive social interactions.

Completed Partnership Plan. Client was willing to engage in process. Client agreed to and signed
the Partnership Plan. A copy of the plan was given to the client.
3. Clinician will begin providing Individual Therapy and provide referrals as discussed.
SAMPLE COLLATERAL (311)

1. Clinician received a phone call from client’s grandmother. Client’s grandmother was upset about
client’s recent behavior and provided clinician with an update regarding client’s current functioning.
2. Clinician listened and provided emotional support to grandmother while she explained that client’s
angry outbursts had increased this past week at home. Discussed strategies for handling situations
when client is angry. Introduced de-escalation techniques that will assist grandmother in controlling
client's behavior at home. Grandmother agreed to try the strategies and will check in next week on
progress with treatment.
3. Clinician will follow up with a call to client’s school counselor regarding recent increase in behaviors.
Will also follow up with Grandmother to see if client has made any further progress at home.
SAMPLE COLLATERAL (Family Therapy 311)

1. Met with mom and client to facilitate a family session. Provided a safe place for mom and client to
express their concerns and emotions.
2. Mom requested to meet with clinician and client because she is having a difficult time with client at
home. Provided a safe place for mom and client to express their concerns at home. Mom was
able to express her emotions and client used his listening skills, however, disagreed with mom.
Clinician guided mom and client to express their concerns in a positive way and helped them
reframe their negative words to help clarify their feelings. Discussed client’s increased aggression
and disrespectful behaviors. Client was able to listen and share his frustrations with mom. Client
was able to share he is being bullied at school. Discussed ways client and mom can support each
other at home and created a safety plan due to the client’s increased violent behaviors. Discussed
possible referral for a psychiatric evaluation for client.
3. Clinician will follow up with an individual session with client and also possible medication evaluation
referral.
SAMPLE INDIVIDUAL REHAB (317)

1. Rehab Specialist met with client in in the community. Client continues to exhibit impaired judgment,
low frustration tolerance, and highly reactive when faced with frustrating situations. Appeared
somewhat subdued, although anxious.
2. Rehab Specialist encouraged the client to utilize coping skills such as deep breathing and
relaxation exercises such as taking quick time-outs instead of reacting to situations which trigger
his anxiety. Rehab Specialist and client role-played a recent situation where client’s anxiety was
triggered. Client practiced different responses he could have had other than anxiety, i.e., deep
breathing, walking away, etc. Client was encouraged to use his coping skills when his anxiety is

triggered over the next week. Client was engaged in role play and reported that he would try to
use deep breathing when he is anxious.
3. Rehab Specialist will meet with client in next week and follow up on progress of treatment goals.
Discuss if possible referral to psychiatry is necessary at next session.
SAMPLE INDIVIDUAL THERAPY (341)

1. Client continues to suffer from PTSD symptoms which make it difficult for her to work and sleep at
night. She reports she can’t focus on her day-to-day tasks and is easily startled. She also
continues to be scared at night.
2. Client came in stating that she continues to have nightmares of her husband being murdered in
their home. She has difficulty getting to work and focusing on tasks. Client stated she is afraid of
leaving the house at night or when it is dark outside. Clinician brainstormed with client how to
increase her social support. Client stated she could connect with her church for emotional support.
Problem solved with client on how to increase her amount of sleep. Discussed having her children
visit her at night and to sleep with soothing music. Client agreed to work on finding more ways to
socialize with her friends and leave the house to visit with her family during the day. She continues
to decline referral to psychiatrist. .
3. Clinician will continue to meet with client weekly for Individual Therapy. Will continue to encourage
referrals to resources to increase client’s support network.
SAMPLE GROUP REHABILITATION (355)

1. Client is a 12-year-old male living with his parents and struggling in school. Client isolates himself
and has very few friends. Client was referred to group to help him develop social skills and learn
coping skills to assist him with his symptoms of depression and anxiety.
2. The purpose of this group is to assist clients in decreasing isolative behaviors, increasing proactive
positive social skills, improve communication, improve the decision-making process, encourage
community involvement, and reinforce interpersonal skills.
Facilitator provided psychoeducation to clients about the value of learning various coping skills
when anxious, upset, angry, or just bored. Facilitator taught the following techniques: deep
breathing, self-soothing, and positive self-talk to overcome feelings of frustration. Facilitator actively
engaged clients as they practiced these coping strategies. Facilitator provided encouragement and
praise to the group. Facilitator provided a verbal check out regarding each member's group
experience. Encouraged clients to practice coping skills until the group meeting.
Client attentively listened during group and participated in the deep breathing exercise. Client
responded well to encouragement from his peers and Facilitator. Client stated that he enjoyed the
group and will try to practice new coping skills at home.
3. Client will continue to attend group rehab. Facilitator will continue to coordinate with Individual
Therapist and School Counselor regarding progress in treatment.
EXAMPLE CASE MANAGEMENT PLAN DEVELOPMENT (571)

1. Parents have reached out to family partner in order to assist in advocating for their son during the
Individualized Education Plan (IEP) at the school. The parents would like more services but feel
that they have not been heard at the previous IEP meetings. The client is a 6-year-old boy who is
struggling in school because he is unable to sit for long periods of time, has a hard time focusing,
is quick to anger, and will lash out at teachers or peers when he is upset.
2. The worker encouraged the parents to read the list of items that they would like to see provided to
their son. The parents stated that they would like to have additional support at school so that their
son is able to better manage his behaviors of hurting others or threatening to hurt others. They
would also like to see that their son receives academic support since his grades have suffered this
school year. This worker supported the parents by paraphrasing the requests to the team and
posing questions to see if there were other services that could be provided for the client. This
worker updated the team that the client is doing well in individual play therapy with county mental
health and seems to have decrease his defiant behaviors (hitting, pushing, or kicking others) at
home, to only 4 times per week. He is now able to comply with the parent’s requests and rules at
home more frequently. The parents have made adjustments to their reward system and have
learned that their son responds more favorably to positive reinforcement (adding time outs) rather
than negative reinforcement (taking away TV time or video games). The IEP team will look into
additional supports for the client while at school in order to assist in decreasing his emotional
outbursts at school, as it seems the WRAP meetings have helped decrease the emotional outbursts
at home. Having the additional supports will help the client cope with his anger and learn new
mechanisms in which to display his frustrations, which will hopefully help create a more constructive
learning environment for him to focus on his academic assignments.
3. WRAP meeting is scheduled for tomorrow. Family partner will follow up on the IEP meeting with a
collateral contact with the parents on the phone to check on and see their perception of the IEP
and possibly create a list of any issues that were not discussed or any areas that need further
discussion. Family Partner will coordinate with individual therapist to update her on the supports
that the school district will provide so that she is aware of the changes at school.
EXAMPLE CASE MANAGEMENT LINKAGE (561)

1. Therapist spoke with Client’s TBS worker to coordinate services and plan a team meeting and to
plan a team meeting with all service providers.
2. Therapist provided an update on client’s short-term and long-term goals. Therapist spoke of how
client was doing in therapy with new therapist. Therapist discussed client’s general presentation
and content during individual therapy sessions. Therapist inquired about client’s behavior with TBS
worker and at school. TBS worker stated client has been doing really well and has accomplished
many of his treatment goals. TBS worker stated client has been doing a great job of processing
anger in a healthy manner and behaving in school. TBS worker stated client may be discharged
this summer from the TBS program. This therapist stated client and therapist are continuing to
establish rapport and client is able to communicate his needs effectively.
3. Therapist will continue to communicate regularly with TBS worker when appropriate.
SAMPLE CRISIS INTERVENTION

1. Received a call from manager of client’s residence. Manager reported that client was yelling
repeatedly, although not at any particular person. Manager stated that client’s behavior is
frightening other residents, although she was unsure whether there was any direct threat. Client
has a history of stopping meds and substance use, which have resulted in decompensation and
hospitalization due to similar behavior in the past.
2. Visited client at his residence. Client was extremely agitated, with considerable delusional content
expressed. Appeared to be responding to internal stimuli. Client admitted that he has not been
taking meds – states that they are poison. Was only able to redirect to coherent interaction from
brief periods before client would return to somewhat incoherent rambling speech, containing ideas
of reference and delusional material. Manager stated that she can’t keep him in the residence in
his current state, although said that she would accept him back if he gets back on his medication
and his behavior stabilizes. Called for police for a 5150 to PES for evaluation and stabilization.
Provided reassurance to client while waiting for police and transport, and after their arrival. Client
became slightly more subdued when officers arrived and when told that he was going to hospital.
Was reassured that he was not being arrested, only being taken to hospital on a hold to help him
get re-stabilized.
3. Will check with PES after they have evaluated to see whether they will admit to inpatient, or restart
meds and discharge back to residence. Will inform PES that unless client clears considerably,
residence will not accept back. Will keep residence manager informed of client’s state in terms of
discharge.
SAMPLE IHBS SERVICE

1. Staff met with the client at his home in order to assist the client with continuing to learn and utilize
coping skills to effectively manage feelings related to his anger outbursts and impulse control.
2. Staff encouraged the client to process what coping skills have and have not worked with for him
this past week. He stated that remaining calm helped him stay safe at school. Client shared that
some kids at school tried to bully him, but he was able to avoid the fight and stay safe. Staff and
client discussed and reinforced the use of his positive coping skills: taking space, deep breathing,
and listening to music. Staff encouraged client to continue to use his coping skills when triggered.
3. Staff will continue to work with client’s ICC coordinator in order to update client’s progress towards
goals.
SAMPLE ICC SERVICE (564)

1. ICC coordinator (ICC) contacted CFS worker regarding housing issues for biological mother. Social
worker (SW) stated the client continues to display concerning behaviors such as struggles with
direction and aggressive behavior towards peers.
2. ICC spoke with the child’s CFS social worker regarding the support the SW feels the mother needs
in order to successfully reunify with her child. SW states that the mother needs the support with
finding housing. SW states that she is going to send ICC some links in regard to possible housing
options for biological mom. ICC discussed how the mother’s visits with her child have been going.
SW stated that the child and mother continue to have good visits with no behavioral concerns. ICC
discussed the importance of the mother gaining the skills to handle concerning behavior when the
child is reunified. Biological mother at this time does not see many of the concerning behaviors
because she only sees client once a week. ICC discussed possible referral to parenting skills class
for mom.
3. ICC will continue to provide ICC services to help coordinate client’s care and provide case
management during possible family reunification. Referral to Wraparound may be discussed in the
future.
11.5. SAMPLE PARTNERSHIP PLAN GOALS

SAMPLE CHILDREN’S CASE MANAGEMENT PLAN
Clinical Treatment Goals:
Improve ability to maintain safe behavior while living at home with mom, which includes identifying
triggers of self-harm behavior and suicidal ideation, so that client can remain at home with mom.
Strategies to Achieve Goals:
1. Case manager will provide coordination of care with school staff, psychiatrist, and therapist in order
to maintain current placement at least 1 time per month.
2. Consult with child protective services as needed.
3. Link to additional supportive services to help client maintain home and school placement as
needed.
4. Explore possible referral to Transitional Age Youth (TAY) program.
SAMPLE CLINICAL PLAN 1

Client will work on decreasing her behavior of isolation, by participating in social activities at least 1 time
per week as reported by client.
The client will work on replacing her negative self-talk (low self-esteem & poor body image) with a more
positive self-image as reflected in her individual therapy progress at least 1 time per week as reported by
client.
1. Client will participate in individual therapy sessions weekly in order to decrease negative self-talk
and work on positive self-image that will decrease depressive symptoms.
2. Client will take her medications as prescribed and attend all scheduled psychiatric appointments.
3. Case manager and clinician will work with client on increasing her social activities so that she can
work on her isolation at least 1 time per month.
SAMPLE CLINICAL PLAN 2

Client will decrease symptoms of Post-Traumatic Stress Disorder, including hyper-arousal, anxiety, fear
and impulsive behavior that interfere with social and emotional development as reported by client.
1. Client will participate in individual therapy sessions weekly in order to address mental health
symptoms related to PTSD and increase coping skills.
2. Cognitive Behavioral Therapy will be utilized to assist client with fear and impulsive behaviors at
least 1 time per week.
3. Client will take her medications as prescribed and attend all scheduled psychiatric appointments.
4. Case manager and clinician will work with client on increasing her social activities at least monthly.
5. Possible referral to group therapy.
SAMPLE ADULT CASE MANAGEMENT PLAN

Identify, coordinate, and monitor services that address the mental health symptoms - reduce depressive
and anxiety symptoms, decrease distress, irritability, anger outbursts, develop and implement effective
coping skills that will assist the client in stabilization of housing.
Client will reduce angry outbursts, swift and harsh statements towards others and use of abusive
language towards others from 10 instances to 6 per week. She will do this by learning appropriate ways
to express her anger, direct communication with the person she is angry with or expressing her feelings
to a trusted adult. By doing this she will have appropriate boundaries with her family.
1. Case manager on a weekly basis will assist client in addressing issues that interfere with client's
ability to maintain stable housing and help client develop new ways to cope with impulsivity.
2. Client will work with client on a weekly basis to increase independent skills related to finding and
maintaining stable housing
3. Case manager will assist client in accessing psychiatric services and providing referrals as needed.
4. Provide assistance with linkages to housing support and other services as needed.

APPENDICES

APPENDIX A. MEDI-CAL DIAGNOSIS LISTS
MEDI-CAL INCLUDED DIAGNOSIS GROUPS
A. Pervasive Developmental Disorders (PDD), except Autistic Disorder excluded (Currently,
DSM IV-TR diagnostic criteria must be used for PDD Disorders, per MHSUDS Information
Notice No: 16-051)
B. Neurodevelopmental Disorders
C. Schizophrenia Spectrum and Other Psychotic Disorders
D. Bipolar and Related Disorders
E. Depressive Disorders
F. Anxiety Disorders
G. Obsessive-Compulsive Disorders
H. Trauma- and Stressor-Related Disorders
I. Dissociative Disorders
J. Somatic Symptom and Related Disorders
K. Feeding and Eating Disorders
L. Elimination Disorders
M. Sleep-Wake Disorders
N. Sexual Dysfunction Disorders
O. Gender Dysphoria
P. Disruptive, Impulse-Control, and Conduct Disorders
Q. Substance-Related and Addictive Disorders
R. Neurocognitive Disorders
S. Personality Disorders
T. Paraphilic Disorders
U. Other Mental Disorders
V. Medication-Induced Movement Disorders and Other Adverse Effects of Medication
W. Other Conditions That May Be a Focus of Clinical Attention
X. No Diagnosis - The Z03.89 code can only be used when claiming for services
provided during the assessment period when a diagnosis has not yet been
established.
To continue claiming the diagnosing clinician must complete one of the following
before the assessment period (e.g., 30/60 days) expires:
(See also detail below)
MEDI-CAL EXCLUDED DIAGNOSIS GROUPS

A client may receive services for an included diagnosis even though an excluded diagnosis may also be
present. Excluded diagnosis shall be a secondary diagnosis, services shall focus on mental health
treatment.

APPENDIX B. CCBHS-MHP OUTPATIENT INCLUDED DIAGNOSIS LIST
A copy of the most recent version of this list is available at

https://cchealth.org/mentalhealth/clinical-documentation/#Documents

CCMHP Outpatient Included Diagnosis List
Effective 02/09/21
Note: All diagnoses that are lined out in red have been removed from the Included
Diagnosis list. Please refer to the DHCS MHSUDS Information Notice specified.
ICD-10:
Required for
ShareCare
Billing DSM-5 DSM-5 Narrative Description
F20.0 295.3 Schizophrenia, paranoid type (narrative from DSM-IV-TR manual)
Schizophrenia, disorganized type (narrative from DSM-IV-TR
F20.1 295.1
manual)
F20.2 295.2 Schizophrenia, catatonic type (narrative from DSM-IV-TR manual)
Schizophrenia, undifferentiated type (narrative from DSM-IV-TR
F20.3 295.9
manual)
F20.5 295.6 Schizophrenia, residual type (narrative from DSM-IV-TR manual)
F20.81 295.4 Schizophreniform disorder
F20.89 298.9 Unspecified schizophrenia spectrum and other psychotic disorder
F20.9 295.9 Schizophrenia
F21 301.22 Schizotypal personality disorder
F22 297.1 Delusional disorder
F23 298.8 Brief psychotic disorder
F24 297.3 Shared psychotic disorder (narrative from DSM-IV-TR manual)
F25.0 295.7 Schizoaffective disorder, bipolar type
F25.1 295.7 Schizoaffective disorder, depressive type
Schizoaffective disorder, unspecified (for reference, ICD-10: Other
F25.8 295.7
Schizoaffective disorders)
Schizoaffective disorder, unspecified (for reference, ICD-10:
F25.9 295.7
Schizoaffective disorder, unspecified)
Other specified schizophrenia spectrum and other psychotic
F28 298.8
disorder
F29 298.9 Unspecified schizophrenia spectrum and other psychotic disorder
Bipolar I disorder, current or most recent episode manic,
F30.10 296.4 unspecified (for reference, ICD-10: Manic episode without psychotic
symptoms, unspecified)
Bipolar I disorder, current or most recent episode manic, manic (for
F30.11 296.41 reference, ICD-10: manic episode without psychotic symptoms,
mild)

ICD-10:
Required for
ShareCare
Bipolar I disorder, current or most recent episode manic, moderate
F30.12 296.42 (for reference, ICD-10: Manic episode without psychotic symptoms,
moderate)
Bipolar I disorder, current or most recent episode manic, severe (for
F30.13 296.43 reference, ICD-10: Manic episode without psychotic symptoms,
severe)
Bipolar I disorder, current or most recent episode manic, with
F30.2 296.44 psychotic features (for reference, ICD-10: Manic episode, severe,
with psychotic symptoms)
Bipolar I disorder, current or most recent episode manic, in partial
F30.3 296.45 remission (for reference, ICD-10: Manic episode in partial
remission)
Bipolar I disorder, current or most recent episode manic, in full
F30.4 296.46
remission (for reference, ICD-10: Manic episode in full remission
F30.8 296.4
unspecified (for reference, ICD-10: Other manic episodes)
F30.9 296.4
unspecified (for reference, ICD-10: Manic episode, unspecified)
F31.0 296.4 Bipolar I disorder, current or most recent episode hypomanic
F31.10 296.4
unspecified
F31.11 296.41 Bipolar I disorder, current or most recent episode manic, mild
F31.12 296.42 Bipolar I disorder, current or most recent episode manic, moderate
F31.13 296.43 Bipolar I disorder, current or most recent episode manic, severe
Bipolar I disorder, Current or most recent episode manic, With
F31.2 296.44
psychotic features
Bipolar I disorder, current or most recent episode depressed,
F31.30 296.5
unspecified
F31.31 296.51 Bipolar I disorder, current or most recent episode depressed, mild
F31.32 296.52
moderate
F31.4 296.53
severe
Bipolar I disorder, Current or most recent episode depressed, with
F31.5 296.54
psychotic features
Bipolar I disorder, current or most recent episode unspecified (for
F31.60 296.7 reference, ICD-10: Bipolar disorder, current episode mixed,
unspecified)
F31.61 296.89 Bipolar II disorder, with mixed features

ICD-10:
Required for
ShareCare
F31.63 296.7 reference, ICD-10: Bipolar disorder, current episode mixed,
moderate)
F31.63 296.7 reference, ICD-10: Bipolar disorder, current episode mixed, severe,
without psychotic features)
F31.63 296.7 reference, ICD-10: Bipolar disorder, current episode mixed, severe,
with psychotic features)
Bipolar I disorder, current or most recent episode depressed, in full
F31.7 296.56 remission (for reference, ICD-10: Bipolar disorder, currently in
remission, most recent episode unspecified)
Bipolar I disorder, current or most recent episode hypomanic, in
F31.71 296.45
partial remission
Bipolar I disorder, current or most recent episode hypomanic, in full
F31.72 296.46
remission
Bipolar I disorder, current or most recent episode manic, in partial
F31.73 296.45
remission
Bipolar I disorder, current or most recent episode manic, in full
F31.74 296.46
remission
Bipolar I disorder, current or most recent episode depressed, in
F31.75 296.55
partial remission
F31.76 296.56
remission
Bipolar I disorder, current of most recent episode depressed, in
F31.77 296.55
partial remission, with mixed features
F31.78 296.56
remission, with mixed features.
F31.81 296.89 Bipolar II disorder
F31.89 296.89 Other specified bipolar and related disorder
Bipolar I disorder, current or most recent episode hypomanic,
F31.9 296.4
unspecified
F31.9 296.4
unspecified
F31.9 296.5
unspecified
F31.9 296.7 Bipolar I disorder, current or most recent episode unspecified
F31.9 296.8 Unspecified bipolar and related disorder
F32.0 296.21 Major depressive disorder, single episode, mild
F32.1 296.22 Major depressive disorder, single episode, moderate
F32.2 296.23 Major depressive disorder, single episode, severe
ICD-10:
Required for
ShareCare
F32.3 296.24 Major depressive disorder, single episode, with psychotic features
F32.4 296.25 Major depressive disorder, single episode, in partial remission
F32.5 296.26 Major depressive disorder, single episode, in full remission
F32.81 635.4 Premenstrual dysphoric disorder
F32.89 311 Other specified depressive disorder
F32.9 296.2 Major depressive disorder, single episode, unspecified
F32.9 311 Unspecified depressive disorder
F33.0 296.31 Major depressive disorder, recurrent episode, mild
F33.1 296.32 Major depressive disorder, recurrent episode, moderate
F33.2 296.33 Major depressive disorder, recurrent episode, severe
Major depressive disorder, recurrent episode, with psychotic
F33.3 296.34
features
F33.40 296.36 Major depressive disorder, recurrent episode, in full remission
F33.41 296.35 Major depressive disorder, recurrent episode, in partial remission
F33.42 296.36 Major depressive disorder, recurrent episode, in full remission
F33.8 296.3 Major depressive disorder, recurrent episode, unspecified
F33.9 296.3 Major depressive disorder, recurrent episode, unspecified
F34.0 301.13 Cyclothymic disorder
F34.1 300.4 Persistent depressive disorder (dysthymia)
F34.81 296.99 Disruptive mood dysregulation disorder
Other specified depressive disorder (for reference, ICD-10: Other
F34.89 311
specified persistent mood disorder)
Persistent depressive disorder (dysthymia) (for reference, ICD-10:
F34.9 300.4
Persistent mood [affective] disorder)
Unspecified depressive disorder (for reference, ICD-10: Unspecified
F39 311
mood [affective] disorder)
F40.00 300.22 Agoraphobia
Agoraphobia with panic disorder (narrative from DSM-IV-TR
F40.01 300.21
manual)
Agoraphobia without panic disorder (narrative from DSM-IV-TR
F40.02 300.01
manual)
F40.10 300.23 Social anxiety disorder (social phobia)
Social anxiety disorder (for reference, ICD-10: Social phobia,
F40.11 300.23
Generalized)
F40.210 300.29 Specific phobia, animal (for reference, ICD-10: arachnophobia)
F40.218 300.29 Specific phobia, animal
Specific phobia, natural environment (for reference, ICD-10: Fear of
F40.220 300.29
thunderstorms)
F40.228 300.29 Specific phobia, natural environment
F40.230 300.29 Specific phobia, fear of blood
F40.231 300.29 Specific phobia, fear of injections and transfusions
ICD-10:
Required for
ShareCare
F40.232 300.29 Specific phobia, fear of other medical care
F40.233 300.29 Specific phobia, fear of injury
F40.240 300.29 Specific phobia, situational (for reference, ICD-10: Claustrophobia)
Specific phobia, natural environment (for reference, ICD-10:
F40.241 300.29
Acrophobia)
F40.242 300.29 Specific phobia, situational (for reference, ICD-10: Fear of bridges)
F40.243 300.29 Specific phobia, situational (for reference, ICD-10: Fear of flying)
F40.248 300.29 Specific phobia, situational
F40.290 300.29 Specific phobia, other (for reference, ICD-10: Androphobia)
F40.291 300.29 Specific phobia, other (for reference, ICD-10: Gynophobia)
F40.298 300.29 Specific phobia, other
F40.8 300.00 Unspecified anxiety disorder
F40.9 300.29 Specific phobia, other
F41.0 300.01 Panic disorder
F41.1 300.02 Generalized anxiety disorder
Unspecified anxiety disorder (for reference, ICD-10: Other mixed
F41.3 300
anxiety disorders)
F41.8 300.09 Other specified anxiety disorder
F41.9 300 Unspecified anxiety disorder
F42.2 300.3 Obsessive-compulsive disorder
F42.3 300.3 Hoarding disorder
F42.4 698.4 Excoriation (skin-picking) disorder
F42.8 300.3 Other specified obsessive-compulsive and related disorder
F42.9 300.3 Unspecified obsessive-compulsive and related disorder
F43.0 308.3 Acute stress disorder
F43.10 309.81 Posttraumatic stress disorder
F43.11 308.3 Acute stress disorder
F43.12 309.81 Posttraumatic stress disorder
F43.20 309.9 Adjustment disorder, unspecified
F43.21 309 Adjustment disorder, with depressed mood
F43.22 309.24 Adjustment disorder, with anxiety
F43.23 309.28 Adjustment disorder, with mixed anxiety and depressed mood
F43.24 309.3 Adjustment disorder, with disturbance of conduct
Adjustment disorder, with mixed disturbance of emotions and
F43.25 309.4
conduct
F43.29 309.9 Adjustment disorder unspecified
F43.8 309.89 Other specified trauma and stressor related disorder
F43.9 309.9 Unspecified trauma and stressor related disorder
F44.0 300.12 Dissociative amnesia
F44.1 300.13 Dissociative amnesia, with dissociative fugue
F44.2 300.15 Other specified dissociative disorder
ICD-10:
Required for
ShareCare
Conversion disorder (functional neurological symptom disorder),
F44.4 300.11
with abnormal movement
F44.4 300.11
with speech symptoms
F44.4 300.11
with swallowing symptoms
F44.4 300.11
with weakness/paralysis
F44.5 300.11
with attacks or seizures
F44.6 300.11
with anesthesia or sensory loss
F44.6 300.11
with special sensory symptoms
F44.7 300.11
with mixed symptoms
F44.81 300.14 Dissociative identity disorder
F44.89 300.15 Other specified dissociative disorder
F44.9 300.15 Unspecified dissociative disorder
F45.0 300.81 Somatization disorder (narrative from DSM-IV-TR manual)
F45.1 300.82 Somatic symptom disorder
Illness anxiety disorder (for reference, ICD-10: Hypochondriacal
F45.20 300.7
disorder, Unspecified)
F45.21 300.7 Illness anxiety disorder
F45.22 300.7 Body dysmorphic disorder
Illness anxiety disorder (for reference, ICD-10: Other
F45.29 300.7
hypochondriacal disorders)
F45.42 307.8 Unspecified somatic symptom and related disorder
F45.8 300.89 Other specified somatic symptom and related disorder
F48.1 300.6 Depersonalization/derealization disorder
F50.00 307.5 Unspecified feeding or eating disorder
F50.01 307.1 Anorexia nervosa, restricting type
F50.02 307.1 Anorexia nervosa, binge-eating/purging type
F50.2 307.51 Bulimia nervosa
F50.8 307.59 Avoidant/restrictive food intake disorder
F50.81 307.51 Binge-eating disorder
F50.82 307.59 Avoidant/restrictive food intake disorder
F50.89 307.52 Pica, in adults
F50.89 307.59 Other specified feeding or eating disorder
ICD-10:
Required for
ShareCare
F50.9 307.5 Unspecified feeding or eating disorder
Major depressive disorder, severe, single episode with peripartum
F53.0 296.23
onset
F53.1 298.8 Brief psychotic disorder with peripartum onset
F60.0 301 Paranoid personality disorder
F60.1 301.2 Schizoid personality disorder
F60.3 301.83 Borderline personality disorder
F60.4 301.5 Histrionic personality disorder
F60.5 301.4 Obsessive-compulsive personality disorder
F60.6 301.82 Avoidant personality disorder
F60.7 301.6 Dependent personality disorder
F60.81 301.81 Narcissistic personality disorder
F60.9 301.9 Unspecified personality disorder
F63.0 312.31 Gambling disorder
F63.1 312.33 Pyromania
F63.2 312.32 Kleptomania
F63.3 312.39 Trichotillomania (hair-pulling disorder)
F63.81 312.34 Intermittent explosive disorder
Other specified disruptive impulsive control and conduct disorder
F63.89 312.89
(for reference, ICD-10: Other impulse disorders)
Intermittent explosive disorder (for reference, ICD-10: Other impulse
F63.89 312.34
disorder)
F64.0 302.85 Gender dysphoria in adolescents and adults (transsexualism)
F64.2 302.6 Gender dysphoria in children
F64.8 302.6 Other specified gender dysphoria
F64.9 302.6 Unspecified gender dysphoria
F65.0 302.81 Fetishistic disorder
F65.1 302.3 Transvestic disorder
F65.2 302.4 Exhibitionistic disorder
F65.3 302.82 Voyeuristic disorder
F65.4 302.2 Pedophilic disorder
Sexual sadism disorder (for reference, ICD-10: Sadomasochism,
F65.50 302.84
unspecified)
F65.51 302.83 Sexual masochism disorder
F65.52 302.84 Sexual sadism disorder
F65.81 302.89 Frotteuristic disorder
F65.89 302.89 other specified paraphilic disorder
F65.9 302.9 Unspecified paraphilic disorder
F68.10 300.19 Factitious disorder imposed on self
Factitious disorder imposed on self, with predominantly
F68.11 300.19
psychological signs and symptoms
ICD-10:
Required for
ShareCare
Factitious disorder imposed on self, with predominantly physical
F68.12 300.19
signs and symptoms
Factitious disorder imposed on self, with combined psychological
F68.13 300.19
and physical signs and symptoms
F68.A 300.19 Factitious disorder imposed on another
F80.82 315.39 Social pragmatic communication disorder
F80.9 307.9 Unspecified communication disorder
F84.0 299.00 Autism spectrum disorder
F84.2 299.8 Rett's syndrome (narrative from DSM-IV-TR manual)
Other childhood disintegrative disorder (narrative from DSM-IV-TR
F84.3 299.1
manual)
F84.5 299.8 Asperger's syndrome (must use DSM-IV-TR manual)
Other pervasive developmental disorders (narrative from DSM-IV-
F84.8 299.8
TR manual)
Pervasive developmental disorder, unspecified (narrative from
F84.9 299.8
DSM-IV-TR manual)
Attention-deficit/hyperactivity disorder, predominantly inattentive
F90.0 314
presentation
Attention-deficit/hyperactivity disorder, predominantly
F90.1 314.01
hyperactive/impulsive presentation
F90.2 314.01 Attention-deficit/hyperactivity disorder, combined presentation
F90.8 314.01 Other specified attention-deficit/hyperactivity disorder
F90.9 314.01 Unspecified attention-deficit/hyperactivity disorder
Other specified disruptive impulsive control and conduct disorder
F91.0 312.89
(for reference, ICD-10: Conduct disorder confined to family context)
F91.1 312.81 Conduct disorder, childhood-onset type
F91.2 312.82 Conduct disorder, adolescent-onset type
F91.3 313.81 Oppositional defiant disorder
F91.8 312.89 Other specified disruptive, impulse-control, and conduct disorder
F91.9 312.89 Conduct disorder, unspecified onset
F91.9 312.9 Unspecified disruptive, impulse-control, and conduct disorder
F93.0 309.21 Separation anxiety disorder
Disorder of infancy, childhood or adolescence NOS (must use
F93.8 313.9 DSM-IV-TR manual) (for reference, ICD-10: Other childhood
emotional disorders, unspecified)
Disorder of infancy, childhood or adolescence NOS (must use
F93.9 313.9 DSM-IV-TR manual) (for reference, ICD-10: Childhood emotional
disorder, unspecified)
F94.0 313.23 Selective mutism
F94.1 313.89 Reactive attachment disorder
F94.2 313.89 Disinhibited social engagement disorder
ICD-10:
Required for
ShareCare
Social pragmatic communication disorder (for reference, ICD-10:
F94.8 315.39
Other childhood disorders of social functioning)
Social pragmatic communication disorder (for reference, ICD-10:
F94.9 315.39
Other childhood disorders of social functioning)
F95.0 307.21 Provisional tic disorder
F95.1 307.22 Persistent (chronic) motor or vocal tic disorder
F95.2 307.23 Tourette disorder
F95.8 307.2 Other specified tic disorder
F95.9 307.2 Unspecified tic disorder
F98.0 307.6 Enuresis
F98.1 307.7 Encopresis
F98.21 307.53 Rumination disorder
F98.29 307.59 Other specified feeding or eating disorder
F98.3 307.52 Pica, in children
F98.4 307.3 Stereotypic movement disorder
Must use ICD-10 narrative: Other specified behavioral and
emotional disorders with onset usually occurring in childhood and
F98.8 313.9
adolescence. Use DSM-IV-TR criteria for Disorder of infancy,
childhood, or adolescence Not otherwise specified
Must use ICD-10 narrative: Unspecified behavioral and emotional
disorders with onset usually occurring in childhood and
F98.9 313.9
adolescence. Use DSM-IV-TR criteria for Disorder of infancy,
childhood, or adolescence, not otherwise specified
G21.0 333.92 Neuroleptic malignant syndrome **
G21.11 332.1 Neuroleptic-induced parkinsonism **
G24.4 Idiopathic orofacial dystonia (ICD-10 narrative) **
G25.1 333.1 Medication-induced postural tremor **
G25.70 Drug-induced movement disorder, unspecified (ICD-10 narrative) **
G25.71 333.99 Medication-induced acute akathisia **
Extrapyramidal and movement disorder, unspecified (ICD-10
G25.9
narrative) **
R15.0 787.6 Other specified elimination disorder with fecal symptoms
R15.9 787.6 Unspecified elimination disorder with fecal symptoms
Diagnosis Deferred (Illness, unspecified) Code removed per Info
R69
Notice 20-043.
Z03.89 No Diagnosis

APPENDIX C. TITLE 9 SERVICE DEFINITIONS
TITLE 9.
CALIFORNIA CODE OF REGULATIONS
Chapter 11.
Medi-Cal Specialty Mental Health Services
Assessment (§1810.204)
“Assessment” means a service activity which may include a clinical analysis of the history and current
status of a beneficiary’s mental, emotional, or behavioral disorder; relevant cultural issues and history;
diagnosis; and the use of testing procedures.
Plan Development (§1810.232)
“Plan Development” means a service activity which consists of development of client plans, approval of
client plans, and/or monitoring of a beneficiary’s progress.
Mental Health Services (§1810.227)
“Mental Health Services” means those individual or group therapies and interventions that are designed
to provide reduction of mental disability and improvement or maintenance of functioning consistent with
the goals of learning, development, independent living and enhanced self-sufficiency and that are not
provided as a component of adult residential services, crisis residential treatment services, crisis
intervention, crisis stabilization, day rehabilitation, or day treatment intensive. Service activities may
include but are not limited to assessment, plan development, therapy, rehabilitation and collateral.
Therapy (1810.250)
“Therapy” means a service activity which is a therapeutic intervention that focuses primarily on symptom
reduction as a means to improve functional impairments. Therapy may be delivered to an individual or
group of beneficiaries and may include family therapy at which the beneficiary is present.
Rehabilitation (§1810.243)
“Rehabilitation” means a service activity which includes 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.
Collateral (§1810.206)
“Collateral” means a service activity to a significant support person in a beneficiary’s life with the intent
of improving or maintaining the mental health status of the beneficiary. The beneficiary may or may not
be present for this service activity.
Medication Support Services (§1810.225)
“Medication Support Services” means those services which include prescribing, administering,
dispensing and monitoring of psychiatric medications or biologicals which are necessary to alleviate the
symptoms of mental illness. The services may include evaluation of the need for medication, evaluation
of clinical effectiveness and side effects, the obtaining of informed consent, medication education and
plan development related to the delivery of the service and/or assessment of the beneficiary.
Crisis Intervention (§1810.209)
“Crisis Intervention” means a service, lasting less than 24 hours, to or on behalf of a beneficiary for a
condition which requires more timely response than a regularly scheduled visit. Service activities may
include but are not limited to assessment, collateral and therapy. Crisis intervention is distinguished from
crisis stabilization by being delivered by providers who are not eligible to deliver crisis stabilization or who
are eligible, but deliver the service at a site other than a provider site that has been certified by the
department or a Mental Health Plan to provide crisis stabilization.
Case Management (§1810.249)
“Targeted Case Management” (Case Management/ Brokerage/Linkage/Placement) means 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.
TITLE 9 DEFINITION (§1810.227) ~ SPECIALTY MENTAL HEALTH SERVICE
“Mental Health Services” mean those individual or group therapies and interventions that are designed
to provide reduction of mental disability and improvement or maintenance of functioning consistent with
the goals of learning, development, independent living and enhanced self-sufficiency and that are not
provided as a component of Adult Residential Services, Crisis Residential Treatment Services, Crisis
Intervention, Crisis Stabilization, Day Rehabilitation, or Day Treatment Intensive Services. Mental Health
Service activities may include but are not limited to assessment, plan development, therapy, rehabilitation
and collateral.
NOTE: For seriously emotionally disturbed children and adolescents, Mental Health Services provides a
range of services to assist the child/adolescent to gain the social and functional skills necessary for
appropriate development and social integration.

APPENDIX D. SCOPE OF PRACTICE DEFINITIONS
This document is also available at
https://cchealth.org/mentalhealth/provider/

APPENDIX E. GUIDELINES FOR SCOPE OF PRACTICE
This document is also available at
https://cchealth.org/mentalhealth/provider/
APPENDIX F. ABBREVIATIONS
Number
1:1 One to one
1º Primary
2º Due to; Secondary to
24/7 24 hours a day/7 days a week
5150 WIC 72-hour hold for mental health evaluation
5250 WIC 14-day hold
A
Ā before
@ At
A/H Auditory Hallucinations
A/O Alert & Oriented
AA Alcoholics Anonymous
ACBH Antioch Children’s Behavioral Health
ADD Attention Deficit Disorder
ADHD Attention Hyperactive Disorder
ADL Activities of Daily Living
ADOL Adolescent
AFS Alternative Family Services
AM Morning
AMA Against Medical Advice
AOD Alcohol and Other Drugs
AOT Assisted Outpatient Treatment
APPT Appointment
APPROX Approximately
APS Adult Protective Services
ASAP As soon as possible
ASSMT Assessment
ASW Associate of Social Work
ATOD Alcohol, Tobacco, and other drugs
ATTN Attention
AVG Average
AWOL Absence With Out Leave
B
BA Bachelor of Arts
BACR Bay Area Community Resource
BARM Bay Area Rescue Mission
B&C Board & Care
BDI Beck Depression Inventory
BF Boyfriend
BIB Brought in by
Bid Twice a day
Bio Biological
BPD Borderline Personality Disorder
Bro Brother
b/t Between
Bx Behavior
C
C with
C/O Complains of
CALOCUS Child and Adolescent Level of Care Utilization System
CANS Children and Adolescent Needs and Strengths Assessment
CBO Community Based Organization
CBT Cognitive Behavioral Therapy
CCAMH Central County Adult Mental Health
CCBHS Contra Costa Behavioral Health Services
CCBHS-MHP Contra Costa Mental Health Plan
CCC Contra Costa County
CCCMH Central County Children’s Mental Health
CCRMC Contra Costa Regional Medical Center
CD Chemical Dependency
CFS Child and Family Services
CFT Child and Family Team
CHAA Community Health for Asian Americans
CLT Client
CM Case Management
COFY Community Options for Family and Youth
COLL Collateral
CON REP Conditional Release Program
cont. Continuously
CPS Child Protective Services
Crisis Res. Crisis Residential
CSW Community Support Worker
CTI Child Therapy Institute
CWAT County Wide Assessment Team
D
D Divorced
DAU Daughter
Day Tx Day Treatment
DBT Dialectical Behavior Treatment
D/C Discharge
DC Discontinue
DHCS California Department of Health Care Services
DD Developmentally Disabled
DMH Department of Mental Health
DMV Department of Motor Vehicles
DOB Date of Birth
DOS Date of Service
Dr Doctor
DSM Diagnostic & Statistical Manual
DTN Detention
DTO Danger to Others
DTS Danger to Self
DUI Driving Under the Influence
DV Domestic Violence
DVR Diablo Valley Ranch
Dx Diagnosis
Dz Disease
E
EBP Evidence Based Practice
ECAMH East County Adult Mental Health
EFC Emergency Foster Care
EMDR Eye Movement Desensitization Reintegration
EPSDT Early & Periodic Screening, Diagnosis, and Treatment
ER Emergency Room
ERMHS Educationally Related Mental Health Service
EtOH Alcohol
EVAL Evaluation
F
F/U Follow Up
Fa Father
FAS Fetal Alcohol Syndrome
FOI Flight of Ideas
FFT Functional Family Therapy
FSP Full-Service Partnership
G
GAD General Anxiety Disorder
GAF Global Assessment of Functioning
GD Gravely Disabled
Gfa Grandfather
G/F Girlfriend
GLBTQQ Gay, Lesbian, Bisexual, Transgendered, Queer, Questioning
GM Grandmother
Group Tx Group Therapy
H
H Heroin
H&P History and Physical
H&R Hospital and Residential
Hal Hallucinations
H/I Homicidal Ideation
HIPAA Health Insurance Portability & Accountability Act
Hosp Hospitalized
HS High School
HUD Housing and Urban Development
HUSB Husband
HV Home Visit
Hx History
I
ICC Intensive Care Coordination
ICCco Intensive Care Coordinator
ICU Intensive Care Unit
IEP Individual Education Plan
IHBS Intensive Home-Based Service
IMD Institute of Mental Disease
IN-PT Inpatient
IHSS In Home Support Services
J
JACS Juvenile Assessment and Consultation Services (Juvenile Hall)
JMBH John Muir Behavioral Health
JUV Juvenile
K
KTA Katie A.
L
LCSW Licensed Clinical Social Worker
LD Learning Disability
LOCUS Level of Care Utilization System
LMFT Licensed Marriage and Family Therapist
LPT Licensed Psychiatric Technician
LPS Lanterman-Petris-Short
LVN Licensed Vocational Nurse
M
M Male
Ma Married
MD Medical Doctor/Physician
MDD Major Depressive Disorder
Med Hx Medical History
Meds Medications
MFT Marriage & Family Therapist
AMFT Marriage & Family Therapist Intern
MH Mental Health
MHCS Mental Health Clinical Specialist
MHP Mental Health Plan
MHRC Mental Health Rehabilitation Center
MHRS Mental Health Rehab Specialist
MHSA Mental Health Services Act or Prop 63
MHTC Mental Health Treatment Center
MHW Mental Health Worker
MI Motivational Interviewing
MJ Marijuana
MMPI Minnesota Multiphasic Personality Inventory
Mo Mother
MRN Medical Record Number
MRT Mobile Response Team
MSE Mental Status Exam
MSG Message
MST Multisystemic Therapy
MSW Masters of Social Worker (not registered with the board)
Mt. D Mount Diablo Unified School District
MTG Meeting
MWC Miller Wellness Center
N
N/A Not Applicable
NA Narcotics Anonymous
NAMI National Alliance for the Mentally Ill
NARC Narcotic
N/C No Complaints
NEG Negative
NKA No Known Allergies
NKDA No Known Drug Allergies
NOA Notice of Action
NOC Night
NOS Not Otherwise Specified
NPI National Provider Identifier
NS No Show
O
OCC Occasionally
OCD Obsessive Compulsive Disorder
OCE Office of Consumer Empowerment
Od Overdose
OD Officer of the Day
OFF Oppositional Defiant Disorder
OT Occupational Therapy
Outpt Outpatient
P
p.c. After meals
Prn As needed
P/C Phone Call
PCP Primary Care Physician
PD Plan Development
PDD Pervasive Developmental Disorder
PDR Physician’s Desk Reference
PEI Prevention and Early Intervention
PES Psychiatric Emergency Services
PhD Doctor of Philosophy
PHF Psychiatric Health Facility
PHI Protected Health Information
PHN Public Health Nurse
PHQ Patient Health Questionnaire
Pm Afternoon
PN Psychiatric Nurse
PO Probation Officer
Po By mouth
PREG Pregnant
PROB Problem
PROG Progress
PST Problem Solving Therapy
PsyD Doctor of Psychology
Pt Patient
P/T Part Time
PTSD Post-Traumatic Stress Disorder
P/U Pick Up
Q
Q Every
q2h Every 2 hours
QA Quality Assurance
Qam Every morning
Qh Every hour
Qhs At night
Qid Four times a day
R
R/O Rule Out
R&B Room and Board
REC’D Received
Re Regarding
REC Recommend
REG Regular
REHAB Rehabilitation
REL Relationship
ROI Release of Information
REV Review
RI Recovery Innovations
RN Registered Nurse
Rx Prescription
Rxn Reaction
S
S Single
SA Substance Abuse
s/b Should be
SAMHSA Substance Abuse and Mental Health Services Administration
SCHIZ Schizophrenia
SED Severely Emotionally Disturbed
S/S Signs and Symptoms
S/A Suicide Attempt
S/I Suicide Ideation
SIB Self-Injurious Behavior
Sib Sibling
Sis Sister
SOC System of Care
S/O Significant Other
SPIRIT Service Provider Individualized Recovery Intensive Training
SSRI Selective Serotonin Reuptake Inhibitor
START Short Term Assessment of Resources and Treatment
SW Social Worker
Sx Symptoms
T
TAY Transitional Age Youth
T/C Telephone Call
TV Television
TBI Traumatic Brain Injury
TBS Therapeutic Behavioral Service
TCM Targeted Case Management
Tid Three times a day
TAR Treatment Authorization Request
TRO Temporary Restraining Order
Tox Toxicology
TT Transition Team
Tx Treatment
U
UNK Unknown
UON Unusual Occurrence Notice
UR Utilization Review
V
VA Veteran’s Administration
V/H Visual Hallucinations
VM Voicemail
W
W Widowed
W&I California Welfare and Institutions Code
w/o Without
w/ With
WCAMH West County Adult Mental Health
WCCMH West County Children’s Mental Health
WCCUSD West Contra Costa County Unified School District
W/D Withdrawal
WNL Within Normal Limits
WRAP Wellness Recovery Action Plan
Wt. Weight
X
X Multiplied by/times
Y
Y/O Years Old
YSB Youth Service Bureau
YR Year
Symbols
 Psychiatric/ Psychiatrist/Psychology
≤ Less Than or Equal To
≥ Greater Than or Equal To
↑ Increase
↓ Decrease
♀ Female
♂ Male
# Number
% Percent
+ Plus, positive, yes
- Minus, negative, no
” Inches
‘ Feet
? Unknown
& And
@ At
= Equal
APPENDIX G. FORMS
A copy of CCBHS-MHP clinical forms is available here:
http://cchealth.org/mentalhealth/clinical-documentation/

Clinical Documentation Manual

Uploaded by

Copyright:

Available Formats

Clinical Documentation Manual

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Clinical Documentation Manual

Uploaded by

Copyright:

Available Formats

CLINICAL

Revised June 2021

CHAPTER 1. INTRODUCTION/COMPLIANCE .................................................................................... 4

BHSD Clinical Documentation Manual, Rev. June 2021 Page 3 of 121

1.1. WHY DO WE HAVE THIS MANUAL?

BHSD Clinical Documentation Manual, Rev. June 2021 Page 4 of 121

BHSD Clinical Documentation Manual, Rev. June 2021 Page 5 of 121

BHSD Clinical Documentation Manual, Rev. June 2021 Page 6 of 121

2.1. GENERAL PRINCIPLES OF DOCUMENTATION

BHSD Clinical Documentation Manual, Rev. June 2021 Page 7 of 121

BHSD Clinical Documentation Manual, Rev. June 2021 Page 8 of 121

BHSD Clinical Documentation Manual, Rev. June 2021 Page 10 of 121

3.1. THE FLOW OF CLINICAL INFORMATION

4. Partnership Plan 3. Diagnosis

BHSD Clinical Documentation Manual, Rev. June 2021 Page 11 of 121

3.2. THE GOLDEN THREAD

Documentation Linkage - a “Reflection” of the Golden Thread

3.3. MEDICAL NECESSITY

A medically necessary service is one that attempts to impact a functional impairment

3.4. COMPONENTS OF MEDICAL NECESSITY

3.4.1. DIAGNOSTIC CRITERIA

BHSD Clinical Documentation Manual, Rev. June 2021 Page 13 of 121

DIAGNOSIS & MENTAL STATUS

3.4.2. IMPAIRMENT CRITERIA

3.4.3. INTERVENTION RELATED CRITERIA

BHSD Clinical Documentation Manual, Rev. June 2021 Page 14 of 121

3.2.1. CHILD AND ADOLESCENT NEEDS AND STRENGTHS (CANS)

3.2.2 DOCUMENTATION OF FUNCTIONAL IMPAIRMENT

BHSD Clinical Documentation Manual, Rev. June 2021 Page 16 of 121

BHSD Clinical Documentation Manual, Rev. June 2021 Page 17 of 121

4.1. PARTNERSHIP PLAN FOR WELLNESS

BHSD Clinical Documentation Manual, Rev. June 2021 Page 18 of 121

Unplanned Services allowed for claiming

4.1.1. CLIENT PARTICIPATION/AGREEMENT AND SIGNATURES

BHSD Clinical Documentation Manual, Rev. June 2021 Page 20 of 121

4.1.2. TIMELINESS OF PARTNERSHIP PLANS

If the authorization expires (i.e., the Partnership Plan was not

4.1.3. REVISIONS TO THE PLAN

4.1.4. COMPONENTS OF THE PARTNERSHIP PLAN

BHSD Clinical Documentation Manual, Rev. June 2021 Page 21 of 121

4.1.5. PARTNERSHIP PLAN PROCESS ELEMENTS

4.4. COMPONENT DETAILS AND EXAMPLES

BHSD Clinical Documentation Manual, Rev. June 2021 Page 22 of 121

BHSD Clinical Documentation Manual, Rev. June 2021 Page 23 of 121

• Has a spiritual program/connected to a church “I want to go back to school to

• Good physical health get a degree.”

• Adaptive coping skills/ help seeking behaviors “I want to be less depressed.”

• Capable of independent living “I want a girlfriend/boyfriend.”

4.4.3. LIFE GOALS

BHSD Clinical Documentation Manual, Rev. June 2021 Page 24 of 121

The focus could be on a short-term goal (within one year) or a long-

BHSD Clinical Documentation Manual, Rev. June 2021 Page 25 of 121

4.4.5. STRATEGIES TO ACHIEVE GOALS

BHSD Clinical Documentation Manual, Rev. June 2021 Page 26 of 121

Example of a weak and/or Example of an acceptably Explanation of acceptable

4.4.6. TREATMENT OPTIONS (FORMERLY KNOWN AS SERVICE MODALITIES)

BHSD Clinical Documentation Manual, Rev. June 2021 Page 27 of 121

4.4.7. DOCUMENTING LANGUAGE ON THE PARTNERSHIP PLAN

BHSD Clinical Documentation Manual, Rev. June 2021 Page 28 of 121

5.1. ESTABLISHMENT OF THE UR TRACK/ TIMEFRAMES FOR