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initials/date of addition) or wait to include the new information or changes in the final, clean
copy of the Assessment form.
WHAT ABOUT ASSESSING FOR DANGER TO SELF (DTS), DANGER TO OTHERS
(DTO), AND GRAVE DISABILITY (GD)? Risk assessments, such as for DTS, DTO, and GD
do not fall under Assessment. Unless it was during a session where the counselor was working
on the assessment. In that case, the documentation for the risk assessment should be included in
the progress note for that assessment session or service. But the risk assessment alone does not
necessitate a separate document as an assessment note. For example, if during a regularly
scheduled Individual Counseling session, the client discloses thoughts about self-harm that
requires further evaluation to determine intent, means, and plan, it would be documented in the
Individual Counseling session progress note. Once your assessment is completed, follow your
agency’s protocol for addressing risks related to DTS, DTO, or GD.
Since assessment is ongoing and can be done at any point in the treatment process and applies to
all clients, the service does not need to be specifically identified on the treatment plan.
Assessment services can be provided in-person or by telehealth.
Note: For the initial assessment session where intake paperwork is provided, reviewed, and
signatures are obtained in order to enroll or admit the client into the program and the assessment
process is started, the CDM/CPT Code used will be for that labelled as “Intake.” This code is to
be used one time during the client’s episode of care. All other assessment sessions or activities
should be coded as “Individual Counseling.”
WHAT IS TELEHEALTH? A telehealth session means office or outpatient visits via
interactive audio and video telecommunication systems. Please refer to your program
administrator for the specific platform that is used for the interactive audio and video
telecommunication system at your site. We must have the client’s consent to receive services by
telehealth. Please be sure that there is documentation of the client’s consent. When using
telehealth to provide services, best practice is to make sure that the documentation includes
information about how the client’s confidentiality was ensured.
The ability to utilize telephone and telehealth as a means of providing services to our clients is
helpful for ensuring that clients stay connected and have access to the services that are needed.
Although services can be provided from anywhere in the community, both the client and the
provider must be in the state of California at the time the service is rendered. Those clients who
may need to temporarily be out of state for personal business cannot continue to receive
telephone and/or telehealth services while away. If clients are going to be out of state for over
thirty (30) calendar days, this does require that we discharge the client. The documentation
should clearly indicate that you have confirmed that the client is in California. The
documentation also should clearly show that the provider is in California as well.
DO WE NEED TO DO AN INTAKE NOTE? Yes, for all levels of care, there should be a
progress note completed for the intake session. For Intensive Outpatient Treatment and
Outpatient Drug Free levels of care, the “Intake” code should be utilized for billing this service.
This code is intended to be used one time for that initial session. For Residential levels of care,
there should be documentation of an intake session, even though there is no separate billing. The