CONFIDENTIAL PATIENT INFORMATION
See California W & I Code (Section 5328)
Fed. Regs 42 CFR Part 2 /

ENCOUNTER DOCUMENT

Clinic Name

Clinic Address / Client’s Name:
DOB:
MRN #:
FIN #:
Check only one encounter type
Select encounter typeClinicHomeFieldTelephoneSite Visit
If Telephone is selected, it will be billed as 90899-GY for Medicare and 3rd Party / Date
ED Entered / OT Initials
If Home - Indicate Location / If Site Visit – Indicate Location / Date ED Corrected / OT Initials
Adult Group Home / Correctional:
Assisted Living Facility / Inpt Medical / Inpt Psych
Board & Care / ER School / Shelter SNF / Include address where service was provided if not clinic or pt’s home
Child/Youth Group Home / ADAS Residential / Client’s job site
Private Residence / Faith Based Age Specific Community Ctr
Psych Res Tx Ctr / Other Comm Loc Psy Fac–Partial Hosp
Face to Face Y N / Trauma Y N Unknown
Custody In Released / HF SED Assessment HF SED Assessment Not Qualified HF SED Qualified / PCR: ______Date: ______
Substance Abuse Diagnosis
Y N Unknown /
FOR GROUP USE
ONLY
/ Date of
Service / Service
Minutes / Document Minutes / Date of Documentation / Travel
Minutes
Axis
I & II / Axis I & II Treated
Today (Primary First) / Axis I & II
Other Dx / # of Clients / # of Staff
Quantity (Do not include “doc” time) / If same day then enter “S”
Axis III / General Medical Condition Summary Codes / Clinician Credit Reason #: ______Date: ______Initials: ______
Axis V / Co-Therapist Name / Credit Reasons: (1) MD Sig. (2) Clt. Sig. (3) No MTP/CSP (4) Dup Svc (5) Other

INDICATE ONLY ONE CPT CODE FROM THE LIST BELOW

DESCRIPTION / CPT CODE / HCPCS /

DESCRIPTION

/

CPT CODE

/

HCPCS

TARGETED CASE MANAGEMENT SERVICES /
COMPREHENSIVE COMMUNITY CRISIS SERVICES
Case Management – Targeted / 90899-1 SF 01 / T1017-HE /

Crisis Intervention

/

90899 SF 70

/

H2011-HE

Case Management – Non-Billable / 90899-5 SF 05 / Crisis Intervn – Non-Billable / 90899-14 SF 72
Case Management– Non-Billable Travel / 90899-112 SF 05 / Min: /
Crisis Intervn – Non-Billable Travel
/
90899-116 SF 72
/
Min:
Case Management –Noncompliant Chart / 90899-106 SF 06 / Med Escort / 90899-10 SF 72 /
H2011-HE
COMPREHENSIVE COMMUNITY MH SERVICES / CPT MODIFIERS
Family Therapy with Pt / 90847 SF 10 / H2015-HE / AJ LCSW
Family Therapy without Pt / 90846 SF 10 / H2015-HE / AH PhD
Comp Com Svc MH – Other Assess * / 90899-6 SF 30 / H2015-HE / 22 Unusual Procedural Svcs
Comp Com Svc MH – Non-Billable / 90899-13 SF 31 / 32 Mandated Svc / Repeat Service Corrections Only
Comp Com Svc MH – Non-Billable Travel / 90899-113 SF 31 / Min: / 52 Reduced Svc / Date Corrected / OT Initials
Comp Com Svc MH – Noncompliant Chart / 90899-110 SF 32 / H2015-HE / 76 Repeat Svc Same Provider
Initial Comp MH Evaluation / 90801 SF 30 / H2015-HE / 77 Repeat Svc Diff Provider
Neurobehavioral Status Exam (SF 30) / 96116 SF 30 / H2015-HE /
ENTER EBP AND SELECT SS THAT APPLY TO THIS SERVICE
Psych Test by Psychologist (SF 30) / 96101 SF 30 / H2015-HE / EVIDENCE BASED PRACTICES (EBP)
Psych Test by Computer (SF 30) / 96103 SF 30 / H2015-HE / EBP:
Indiv Therapy/Counseling 20-30 min / 90804 SF 40 / H2015-HE /
SERVICE STRATEGIES (SS) – May choose up to three
Indiv Therapy/Counseling 45-50 min / 90806 SF 40 / H2015-HE / M50 Peer and/or Family Delivered Services
Indiv Therapy/Counseling 75-80 min / 90808 SF 40 / H2015-HE /
M51 Psychoeducation
Therapeutic Behavioral Svc ** / 90899-19 SF 58 / H2019-HE / M52 Family Support
Group Psychotherapy / 90853 SF 50 / H2015-HE / M53 Supportive Education
Group Psychotherapy-Multi-Family / 90849 SF 50 / H2015-HE / M54 Delivered in Partnership w/Law Enforcement
Group Educational / 99078 SF 50 / H2015-HE / M55 Delivered in Partnership w/Health Care
Group Therapy - Non-Billable / 90899-70 SF 51 / M56 Delivered in Partnership w/Social Svcs
Group Therapy - Non-Billable Travel / 90899-114 SF 51 / Min: / M57 Delivered in Partnership w/Sub Abuse Svcs
Group Therapy - Noncompliant Chart / 90899-108 SF 52 / M58 Integrated Services for MH and Aging
COMPREHENSIVE COMMUNITY MEDICATION SERVICES / M59 Integrated Svcs for Mental Health and Developmental Disability
Comp Med Svc W or W/O Pt Present * / 90899-8 SF 60 / H2010-HE / M60 Ethnic-Specific Service Strategy
Comp Med Svc – Non-Billable Travel / 90899-115 SF 68 /
Min:
/ M61 Age-Specific Service Strategy
Comp Med Svc –Noncompliant Chart / 90899-109 SF 67 / / M99 Unknown Service Strategy
OTHER SERVICE / Signature: ______
Clinician Name, Lic., Job Class
I authorize HCA to bill for services indicated on this fee sheet. I certify that the services shown on this sheet were furnished by me personally, that the services were medically necessary.

*These services will be billed ‘For Denial Only’ with CPT 90899-GY for Medicare and 3rd Party Insurances

**These services will be billed ‘For Denial Only’ with CPT 90899 for 3rd Party Insurances

CONFIDENTIAL PATIENT INFORMATION
See: Cal W & I Code, Section 5328 / Name:
DOB:
MRN:

GROUP PROGRESS NOTE

Clinician Name (Print) / Date of Service / Date Written (if late entry)
Clinician Name, Lic., Job Class
Service Minutes / Documentation Minutes / Travel Minutes
Encounter Type Select encounter type
Type of Service Group Treatment
Language in which client received services, if other than English: Spanish Vietnamese Other (Specify) ______
Interpreter utilized? (Describe in Progress Note)
Diagnosis Treated Today:
GROUP THERAPY
General Group Focus: Overall focus of the group .
Client Service Plan Problem/Impairment/Symptom:
Intervention (Provider #1):
Intervention (Provider #2): N/A
Client Response:
Overall Progress toward Client Service Plan Objective(s):
Plan:
Additional Comments:
Signature/Title (Provider #1) or Group Leader’s Initial if using cont. page / Signature/Title (Provider #2
Co-Signature (If reguired) / Co-Signature (If required)
CONFIDENTIAL PATIENT INFORMATION
See: Cal W & I Code, Section 5328 / Name:
DOB:
MRN:
Clinician Name (Print) / Date of Service / Date Written
(if late entry) / Continuation
Progress Note: Page / of
Clinician Name, Lic., Job Class
Service minutes / Documentation time / Travel Time

Group ED-PN 5.0 (rev. 6/20/11) Therapist’s Initials ______

Signature/Title (Provider #1) / Signature/Title (Provider #2
Co-Signature (If reguired) / Co-Signature (If required)

Group ED-PN 5.0 (rev. 6/20/11) Therapist’s Initials ______