Medicaid Session Note

Date of Session Start Time End Time CPT code; 90791 diagnostic eval; 90832 16-37 min., 90834 38-52 min., 90837 53 or more min.. 90846 30 min+ family w/o cx present; 90847 30+ min family w cx present Who was present NOTE RELATES TO GOAL 1, 2, 3 (from treatment plan) OR case management or eval or treatment planning or other Place of Service (office, telemedicine) Responsible Counselor, name, degree, license # Session content, treatment interventions, consistent with goals and objectives Client/family response to session and level of participation (Could they list how to apply skills being taught Did they ‘not get it’, refuse to participate, resist, etc): Progress toward goals of treatment plan (in emotional/behavioral terms): Plan for next appointment (include date) or discharge plan. Evidence of continued need, diagnosis change, or previous no-show discussion: