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December 2016 Texas Medicaid Provider Procedures Manual

Behavioral Health, Rehabilitation, and Case Management Services Handbook : 7 Screening, Brief Intervention, and Referral to Treatment (SBIRT) : 7.6 Documentation Requirements

Client record documentation must support medical necessity for the SBIRT services provided and must be maintained by the SBIRT provider and made readily available for review when requested by the Health and Human Services Commission (HHSC) or its designee. SBIRT documentation for screening must include the following:
Screening results from a standardized screening tool or laboratory results such as BAC, toxicology screen, or other measures showing risk for alcohol or substance abuse and the specific screening tool used.
Documentation for SBIRT brief intervention sessions must include a client-centered plan for the delivery of medically necessary services that supports the use of procedure code 99408. The plan must include all of the following:
If subsequent sessions are indicated, the provider who performed the SBIRT session must document that a follow up SBIRT appointment was made and with whom, or document another mechanism established to reassess progress
Services are subject to retrospective review to ensure that the documentation in the client’s medical record supports the medical necessity of the services provided.

Texas Medicaid & Healthcare Partnership
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