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Clarification of Documentation Requirements for Psychotherapy Services

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Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to Medicaid members who are enrolled in their MCO. Administrative procedures, such as prior authorization, precertification, referrals, and claims and encounter data filing, may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the member’s specific MCO for details.

On July 1, 2023, the Texas Medicaid & Healthcare Partnership (TMHP) will update the Texas Medicaid Provider Procedures Manual, Behavioral Health and Case Management Services Handbook, subsection 4.2.2, “Psychotherapy Services,” to clarify language about the treatment plan as it relates to the documentation requirements for psychotherapy clinical notes.

For the treatment plan documented in the clinical notes, the provider only needs to specify the goal and objective that are being addressed in the psychotherapy session for the person receiving services.

The following documentation requirements for psychotherapy clinical notes will continue to apply:

  • Diagnosis
  • Symptoms
  • Functional status
  • Focused mental status examination (if indicated)
  • Prognosis
  • Progress
  • Name, signature, and credentials of the individual performing the service or services

For more information, call the TMHP Contact Center at 800-925-9126.