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December 2016 Texas Medicaid Provider Procedures Manual

Behavioral Health, Rehabilitation, and Case Management Services Handbook : 8 Substance Use Disorder (SUD) Services (Abuse and Dependence) : 8.9 Documentation Requirements

8.9
All services require documentation to support the medical necessity of the service rendered, including SUD services.
All SUD services are subject to retrospective review. All documentation must be maintained in the client’s medical record and be made available upon request.

Texas Medicaid & Healthcare Partnership
CPT only copyright 2014 American Medical Association. All rights reserved.