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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 : 6.9 Psychiatric Diagnostic Interviews : 6.9.3 Domains of a Clinical Evaluation

6.9.3
The following domains must be included in the evaluation documentation:
The treating provider must document the medical necessity for the chosen treatment in the client’s medical record and also include the diagnosis code that most accurately describes the client’s condition that necessitated the psychiatric diagnostic interview (procedure code 90801 or 90802). The medical record (inpatient or outpatient hospital records, reports, or progress notes) must be signed and dated by the performing provider, and should be clear and concise, documenting the reasons for the psychiatric diagnostic interview, and the outcome.

Texas Medicaid & Healthcare Partnership
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