Documentation Standards


Mental Health service providers (county-operated and contracted) are required to meet client chart documentation standards as established by Medi-Cal and the Division of Behavioral Health Services.  Providers are responsible for ensuring that clients meet medical necessity and target population guidelines, understand and apply both billable and non-billable service codes, and how to submit Medi-Cal claims that comply with State and Federal statutory and regulatory requirements.  The Division of Behavioral Health Services offers documentation trainings throughout the year. 

Below are brief descriptions of the trainings provided as well as a reference list of materials referred to during training.

Documentation Training is offered to provider staff throughout the year (see Training Calendar).

Adult Documentation Day 1:
Target Audience: Direct service staff and clinical supervisors; appropriate for Avatar users and non-users

  • Introduction to the Mental Health Plan
  • Medical Necessity and Cultural Competence
  • Review Clinical Documentation Requirements/Standards, including Avatar Clinical Work Station
  • Review of Co-Occurring Disorders Assessments
  • Treatment Planning Review and Practice Session

Adult Documentation Day 2:
Target Audience: Direct service staff and clinical supervisors; appropriate for Avatar users and non-users

  • Connects clinical practice and documentation
  • Review Progress Notes and Service Codes
  • Mental Health Services Act Service Codes (included for applicable programs)
  • Billable versus Non-Billable

Please Note:  Adult Documentation Day 1 and Day 2 are recommended to be taken together but may be taken separately depending on training needs.

Children Documentation Day 1:
Target Audience: Direct service staff and clinical supervisors; appropriate for Avatar users and non-users

  • Introduction to the Mental Health Plan
  • Medical Necessity and Cultural Competence
  • Review Clinical Documentation Requirements/Standards, including Avatar Clinical Work Station
  • Treatment Planning Review and Practice Session

Children Documentation Day 2:
Target Audience: Direct service staff and clinical supervisors; appropriate for Avatar users and non-users

  • Connects clinical practice and documentation
  • Review Progress Notes and Service Codes, including Katie A. specific codes
  • Mental Health Services Act Service Codes (included for applicable programs)
  • Billable versus Non-Billable

Please Note:  Children Documentation Day 1 and Day 2 are recommended to be taken together but may be taken separately depending on training needs.

See resource materials below related to documentation:

Avatar Service Codes Definitions/Training Guide

Co-Billing Case Consultations - Revised for Avatar

Members' Handbook

Sacramento County Approved Acronyms & Abbreviations

For Policies & Procedures (P & P) related to documentation requirements, see our P & P webpage or send an email to QMInformation@saccounty.net



 
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