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CLINICAL DOCUMENTATION MANUAL

CLINICAL DOCUMENTATION GUIDE 2017 CONTRA COSTA COUNTY BEHAVIORAL HEALTH Contra Costa County DOCUMENTATION MANUAL v 2017 2 TABLE OF CONTENTS Chapter 1 Introduction/Compliance Why do we have this MANUAL ? 4 Compliance 5 Utilization Review 6 Chapter 2 General Principles of DOCUMENTATION General Principles of DOCUMENTATION 7 Signatures 9 Co-Signatures 9 Chapter 3 Establishment of Medical Necessity Flow of CLINICAL Information 10 Assessment 10 Medical Necessity 11 Components of Medical Necessity 13 Diagnostic Criteria 13 Impairment Criteria 13 Intervention Criteria 14 Chapter 4 Treatment Planning Partnership plan for Wellness 15 Client Participation and Signatures 16 Timeliness of Partnership Plans 16 Revisions to the plan 17 Components of the Partnership plan 17 Partnership plan Process Elements 17 Component Details and Examples 18

compliance plans or fraud charges have been implemented. The intent of this compliance plan is to prevent fraud and abuse at all levels. The compliance plan particularly supports the integrity of all health data submissions; as evidenced by accuracy, reliability, validity, and timeliness.

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