ACBHCS QA 4.2013 - Alameda County Behavioral Health

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outpatient/OFFICE PSYCHIATRIC PROGRESS NOTE COUNSELING AND/OR COORDINATION OF CARE client’s Name: _________________________________________________________Date of Visit:______________________ Interval History:__________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ Interval Psychiatric Assessment/ Mental Status Examination: ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ Current Diagnosis:_________________________________________________________________________________________ Diagnosis Update:_________________________________________________________________________________________ Current Medication(s)/Medication Change(s) – No side effects or adverse reactions noted or reported ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ Lab Tests: Ordered Reviewed : ______________________________________________________________________________ ________________________________________________________________________________________________________ Counseling Provided with client / Family / Caregiver (circle as appropriate and circle each counseling topic Discussed and describe below: Diagnostic results/impressions and/or recommended studies Risks and benefits of treatment options Instruction for management/treatment and/or follow‐up Importance of compliance with chosen treatment options Risk Factor Reduction client/Family/Caregiver Education Prognosis _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Coordination of care provided (with client present) with (circle all appropriate and describe below): Coordination with: Nursing Residential Staff Social Work Physician/s Family Caregiver _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Additional Documentation (if needed):_________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Duration of face to face visit w/client:_______min. Start Time _________ Stop Time_________ CPT Code_________________ Greater than 50% of face to face time spent providing counseling and/or coordination of care: Psychiatrist’s Signature:_____________________________________Date:____________________________________________
See hand‐outs Progress Note Templates for: E/M Notes Based on Counseling & Coordination of Care: Inpt & Outp
Page 1 and 2: ACBHCS QA 4.2013
Page 3 and 4: AGENDA • Why we are doing this tr
Page 5 and 6: New InSyst Procedure codes map to M
Page 7 and 8: Retained Procedure Codes Old New CP
Page 9 and 10: Psychiatric Diagnostic Evaluation P
Page 11 and 12: Non E/M Codes (Psychotherapy & Cris
Page 13 and 14: Time Spent in Session: examples 1.
Page 15 and 16: PSYCHOTHERAPY FACE TO FACE TIME = 3
Page 17 and 18: Add‐On Codes (+) Add‐On (+) cod
Page 19 and 20: Crisis Code 377‐90839 (Used Alone
Page 21 and 22: Crisis Code 377‐90839 + 378‐908
Page 23 and 24: Add‐On Code for Additional Servic
Page 29 and 30: Interactive Complexity (+) 491‐ 9
Page 31 and 32: Psychotherapy Add‐on Codes to E/M
Page 33 and 34: Evaluation and Management (E/M) Cod
Page 35 and 36: CPT E/M New client Definition—CBO
Page 37 and 38: Two Paths to E/M Selection • PATH
Page 39 and 40: Path 1: Choosing the E/M Code Based
Page 45: Path 1: Choosing the E/M Code Based
Page 49 and 50: Medical Necessity—CMS • The Cen
Page 51 and 52: General Principles of Documentation
Page 57: Path 2: Choosing the E/M Code Based
Page 63 and 64: See E/M Progress Note Template Base
Page 65 and 66: Medication Support: RN/LVN/Psych Te
Page 67 and 68: Elimination of AB3632 procedure cod
Page 69 and 70: Training Resources: The National Co
Page 71: Resources continued: • AMA Code B

ACBHCS QA 4.2013 - Alameda County Behavioral Health

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