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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 : 6.11 Psychotherapy or Counseling : 6.11.2 Documentation Requirements

6.11.2
Each client for whom services are provided must have supporting documentation included in their medical record. All entries must be documented clearly, be legible to individuals other than the author, and be dated (month/date/year) and signed by the performing provider. Those services not supported by the documentation in the client’s medical record are subject to recoupment. Documentation must include the following:

Texas Medicaid & Healthcare Partnership
CPT only copyright 2011 American Medical Association. All rights reserved.