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December 2016 Texas Medicaid Provider Procedures Manual

Behavioral Health, Rehabilitation, and Case Management Services Handbook : 6 Physician, Psychologist, and Licensed Psychological Associate (LPA) Providers : 6.10 Psychiatric Diagnostic Evaluations : 6.10.5 Domains of a Clinical Evaluation

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 evaluation (procedure code 90791 or 90792). 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 evaluation, and the outcome.

Texas Medicaid & Healthcare Partnership
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