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2012 Texas Medicaid Provider Procedures Manual

Behavioral Health, Rehabilitation, and Case Management Services Handbook : 6. Physician, Psychologist, and Licensed Psychological Associate (LPA) Providers : 6.8 Pharmacological Regimen Oversight and Pharmacological Management Services : 6.8.3 Documentation Requirements

6.8.3
Documentation of medical necessity for pharmacological management must be dated (month/date/year) and signed by the performing provider and must address all of the following information in the client’s medical record in legible format:
Documentation of medical necessity for pharmacological regimen oversight (procedure code M0064) must address the following in the client’s medical record:
Provider has documented the medication history in the client’s records with current signs and symptoms, and new medication modifications with anticipated outcome.
The treating provider must document the medical necessity for the chosen treatment in the client’s medical record as well as the diagnosis code that most accurately describes the client’s condition that necessitated the pharmacological regimen oversight (procedure code M0064) or pharmacological management (procedure code 90862) in the client’s medical record. The medical record (outpatient hospital records, reports, or progress notes) should be clear and concise, documenting the reasons for the pharmacological regimen oversight or pharmacological management treatment and the outcome.

Texas Medicaid & Healthcare Partnership
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