Training Guide: Diagnostic and Clinical Professional Services

Overview

In this section, you will learn about Diagnostic Assesssment, and related Clinical Professional Services, including Explanation of Findings, Psychoeducation, and Clinical Care Consultation. We will also review the key role of the psychotherapist in providing clinical support to providers of ARMHS, Case Management, and CTSS services.

This section of the training guide is often updated Tap here to see a list of updates to this chapter since July 1, 2022.

Introduction

What You Will Learn

As a Clinical Professional member of your team, you play a key role in quality assurance and improvement in the services you and your team members provide to the persons you serve. This quality assurance role extends past Diagnostic Assessment and Psychotherapy. As the assigned Clinical Professional, we will look to you to provide clinical support to providers of ARMHS, Case Management and CTSS providers. This means reviewing assesssment and planning work, progress review and update. This means consulting with providers of these services on the clinical aspects of treatment, offering guidance and direction, and answering questions relating to services, engagement, treatment and progress.

Admission and Discharge for Clinical Professional Services

Admission

All recipients of any service must be open for Clinical Professional Services. Clinical Professional Services should typically have the earliest start date of all services, as this is the service umbrella under which the Diagnostic Assessment is completed, and a DA is required for admission to all other services.

Cues for moving a referral to Clincal Professional Services to Active status include the following:

The individual arrives at the office for an intake DA interview. (The receptionist should change Clincial Professional Services to Active status.)
The individual receives a DA interview at home or in another community location (Diagnostician should call the office to report the start date and change the status to Active.)
We receive an external DA and it is assigned to a Diagnostician for review. (The person assigning the external DA for review should change the status to Active.)

Discharge

Discharge from Clinical Professional services should occur when the individual discharges from the last other service they are providing. The Clinical Supervisor overseeing the discharge should facilitate closing Clinical Professional Services to Previous when approving that discharge.

Diagnostic Assessment

Purpose

The primary service within the Clinical Professional umbrella is the Diagnostic Assessment, required for admission for all of the services we provide. Annual reviews of DAs are required for continuing most services, with updated DAs completed where indicated as necessary by the reviewer.

All mental health/behavioral health services begin with A Diagnostic Assessment, or DA. A DA is conducted by a licensed Mental Health Professional or Clinical Trainee and serves these core purposes:

to identify whether or not a referred individual has a diagnosis (or diagnoses) of mental illness or a behavioral disorder;
to identify the diagnoses and their severity;
to preliminarily determine a referred individual's eligibility for services;
to make recommendations for services based on the individuals diagnoses and the needs to person has identified in the DA and Intake interviews; and
in the case of an annual DA update, one of several strategies we use to assess treatment progress and success..

DA Requirements and Deadlines - General

A DA is required prior to admission and a new DA or review of the previous DA is required annually for continuing community-based mental health services. To establish intitial and continuing eligibiilty, the DA must identify a mental health or behavioral disorder to determine that services are medically necessary due to impairments in functioning or risks of harm, hospitalization or residential treatment resulting from the indvidual's diagnosis, symptoms and/or behavior.*

*Psychotherapy is appropriate for and acute and new onset condition (grief, loss, trauma, etc.) where impairments in functioning or risks of harm, hospitalization or residential treatment may not be immediately evident, but where treatment is needed to address issues related to a recent event. In certain circumstances, this can be provided as Crisis Psychotherapy, not requiring a DA. Please read that portion of this guide for detials.

An update (new) DA is required in the cicrumstances that follow.

-When the client requires services of a greater number or intensity than were recommended in the previous and that they are currently receiving.
-When the client needs new additional mental health services that were not recommended as medically necessary in the previous DA, or if the DA is over one year old.*

*A mental health professional may amend a diagnostic assessment (see page 4 of this linked resource, and understand that we call this a DA Addendum) that is less than 12 months old to include a new service recommendation/referral, provided the client meets all of the eligibility requirements for that service.

-When the client's mental health condition has changed markedly since the client's most recent diagnostic assessment.
-When the client's current mental health condition does not meet the criteria of the client's current diagnosis.
-When client requests it.
-Every three years by internal policy.
-When a child client becomes an adult by age regardless of legal status.

Find additional requirements for eligibility for each of the different services we provide in the guide section for those specific services.

A Diagnostic Assessment is complete after it all of the findings and treatment recommendations have been written and it has been approved by a Licensed Mental Health Professional.

Review of a Previous DA - Procedures

If, during a review of a previous DA, you determined that a new DA is merited, do the following:

Navigate to the DA you are reviewing. Open it in "view."
Set it to expire soon (within a few weeks to give you time to conduct a new DA)
Approve your review and then open it in "view."
Set it to expire on the same date as the previous DA.

Service-Specific Guidelines for Diagnostic Asssessment

What follows are general guidelines for when we complete DAs for specific services. Tap in the table to scroll for more information.

Circumstances or Services	Guidelines
Upon Referral	If a referred client is receiving services elsewhere where a DA is required, please submit an ROI and request the external DA. If the referred indidivdual is not receiving mental health services elsewhere, schedule an Intake DA and Intake Interview. Do not allow difficulties in obtaining an external DA prevent delay of services. If obtaining an external DA is signicantly delayed or unobtainable, schedule an Intake DA.
Generally When	Generally, we conduct DAs to establish and maintain medical necessity for services, following the guidelines per service below. However, we may conduct a DA even if not required under any of the following circumstances (not an inclusive list): -When an individual's behavior, status, or other life circumstances have changed and a new DA may shed light on new medically necessary services. -When making a referral to external services where a DA is necessary and providing a DA will help expedite the start of these services. -When a client has expressed interest in a new service that requires a recent DA and wants to be placed on the referral list for that service and the most recent DA does not recommend thos services and is not appropriate for an addendum (amendment) as desribed above.
Generally When Not	We do not conduct DAs as requested by external providers for whom DA updates are necessary unless we have reason to conduct the DA for reasons related to services we provide. External service providers who require updates to a DA are responsible for finding their own resources for updates to the DA. We can provide copies of DAs when we have conducted them for our own purposes (as required by services we provide as described in this chapter). We generally do not conduct DAs requested by external providers when referrals to services not made by us require a Diagnostic Assessment. However, there may be exceptions to this if producing a new DA will expedite a necessary service from an outside provider (we are person-centered).
Adult Mental Health Targeted Case Management	A recent (within one year prior to the start of services)) Diagnostic Assessment is required that establishes eligibility for AMH-TCM services based upon a diagnosis of SPMI. A new DA is required every three years for Case Management services and ongoing eligibility determination.
ARMHS	A recent (within one year prior to the start of services, unless an older DA less than three years old has recommended the service and the delay is engagement/participation. ) Diagnostic Assessment is required that establishes eligibility for ARMHS based upon a diagnosis of SMI or SPMI. The Diagnotic Assessment should be reviewed annually and a new DA conducted if determined necesssary or recommended by the conclusions of the review.
Behavioral Health Home Services	Only a single DA is required, recent (within one year prior to the start of services).
CTSS	A recent (within one year prior to the start of services) Diagnostic Assessment is required that establishes eligibility for ARMHS based upon a diagnosis of SMI or SPMI. The Diagnotic Assessment should be reviewed annually and a new DA conducted if determined necesssary or recommended by the conclusions of the review.
Housing Stablization Services	Only one DA is necessary, and this only if eligibility for Housing Stabilization Services is based on a mental health diagnosis. There may be other eligibility reasons, including aging, physical disability, etc.
Psychotherapy	The Diagnotic Assessment should be reviewed annually and a new DA conducted if determined necesssary or recommended by the conclusions of the review.

Types of DAs

There are two types of Diagnostic Assessments. (The Extended DA has been eliminated effective 10/18/2022.) These are:

The Standard DA

Used most often, the standard DA consists of an interview and write-up.

Adult Intake DA

The Adult Intake Diagnostic Assessment is a standard DA that explores functioning in more detail for use in determining potential need or eligibility for adult services such as ARMHS, Case Management or Behavioral Health Home Services. Certain componenents in the intake DA map to the Adult Intake Functional Assessment to:

streamline the initial assessment process,
eliminate redundancy and prevent an individual from having to tell his or her story repeatedly, and
facilitate rapid response to the immediate needs that brought the individual to us for service.

Use the Adult Intake DA for all new adult referrals who are seeking, or may be seeking, mental health services beyond psychotherapy.

The Brief DA

Used rarely, the Brief DA consists of an interview and write-up, but includes less information than a standard DA. A breif DA might be appropriate for an individual who will not likely need more that 10 total sessions of any kind of mental health treatment following the DA.

Plan Recovery Team Meetings With DA Updates

During the Diagnostic Assessment update, we strongly recommend that the diagnostician combines the update interview with a Recovery Team Meeting. The purpose of this meeting is to bring together all of the providers and the person served to review progress and identify a plan for going forward. This is a person-centered, recovery-focused way of taking stock, coordinating, building on success, and improving quality.

Resources for Diagnostic Codes

The DSM V is available to all clinicians. Access to an electronic version can be obtained from the Office Manager. There is a hard copy of the DSM V at the 101 office.

The DSM V must be supplemented by other sources, as it does not advise on billable codes. There are a number of sources for understanding when a diagnostic code can be used as a treating diagnosis and you must find a reliable source for this information. One such reference is ICD10data.com. Don't let the appearance of this website put you off. It is a reliable source for identifying when an ICD10 code can be used as a treating diagnosis or when it may need to be more specific.

Interactive Complexity

Document interactive complexity for Diagnostic Assessment when any of the following exist during the visit:

Communication difficulties among participants that complicate care delivery related to issues such as:
High anxiety
High reactivity
Repeated questions
Disagreement
Caregiver emotions or behaviors that interfere with implementing the treatment plan
Evidence is discovered or discussed relating to an event that must be reported to a third party. This may include events such as abuse or neglect that require a mandatory report to the state agency
The mental health provider overcomes communication barriers by using any of the following methods:

Play equipment
Physical devices
An interpreter or translator for members who are not fluent in the same language as the mental health provider or have not developed or have lost the skills needed to use or understand typical language

Screening, Brief Intervention, and Referral to Treatment (SBIRT)

THe state of Minnesota is working to reduce the barriers to substance abuse treatment. One of these initiative is to introduce SBIRT as a tool to screen for, make recommendations and referrals for treatment if needed, and conduct a brief intervention with an individual regarding substance use and/or treatment.

SBIRT replaces the previous Rule 25 assessment necessary to qualify for treatment and can be conducted in a brief session by a licensed clinician or clinical trainee.

Use of this tool and service is strongly recommended if, during the DA Interview, the individual responds affirmatively to questions about use of alcohol, any drugs including marijuana, cocaine or crack, heroin, methamphetamine (crystal meth), hallucinogens, ecstasy/MDMA, or use of prescription medications not as prescribed.

Completion of the screening tools below are also recommended if, in the provision of pyschotherapy, the individual newly indicates substance use may be an impairment to functioning. However, do not document the Substance Abuse Screening and Intervention service type, rather conduct the intervention as a part of the therapy session.

An SBIRT may also be conducted at any time as a stand-alone service, if indicated it is needed as a result of substance use barriers impacting functioning, relationships, or participation in services, and a) has not been conducted recently, or b) there is a recent change (increase) in substance use.

Instructions for Documenting SBIRT

This service can be provided only by Licensed Clinicians or Clinical Trainees, or by Practitioners or Case Managers with LADC credentials.

There are several methods for providing this service. These include:

a separately-documented service provided during the DA Inteview, or
during the Explanation of Findings following the DA Interview,
a screening using the tools below as a part of a therapy session (do noi document as a seoarate service, rather conduct the intervention as a part if the therapy session),
as a stand-alone service as needed.

To provide and document this service, do the following:

Follow these links to the screening tools online:

Adult: TAPS (Tobacco, Alcohol, Prescription medication, and other Substance use Tool)
Adolescents: Screening to Brief Intervention (S2BI)

Conduct the assessment as an interview with the individual.
After completing the screening, tap the print button and save as a pdf or open in Preview or Adobe Reader.
Send the report to Medical Records to be uploaded to the individual's file.
As determined by the screening, the recommendations in the report, and your best clinical judgment make recommendations and conduct a brief intervention using Motivational Interviewing skills.
If successful in engaging the individual, make an Action Plan with the individual including referrals for treatment or other support if needed.
As applicable (see above when to conduct this as a stand-alone service or in conjunction with the DA Interview) document the services using: Substance Abuse Screening and Intervention. This service should not overlap with the DA Interview or Explanation of Findings, or any other service rather should precede or follow it with start/end time
Complete a brief summary of the results in Assessments>Substance Abuse Sreening>SBIRT Substance Abuse Screening.

The SBIRT screening and intervention can be as short as 5 minutes (depending on the results and recommendations) and should not exceed 45 minutes (with exceptions for remarkable results).

Helpful Tips:

Clinical Care Consultation is not for use consulting with other Accend service providers. It is for consulting with outside provides. Use Treatment Supervision Client Specific for this.

Clincal Care Consultation is also not a service provided to parents, rather to providers for services to children.

Explanation of Findings is an option for explaining the results and recommendations of a Diagnostic Assessment to children and their parents.

See also: Family Psychoeducation for a more long-term and intensive support to families of children with emotional disturbance and mental illness.

Clinical Care Consultation

Clinical Care Consultation is a children's service, consiting of clinical care consultation between the treating mental health professional and another provider or educator. Examples of appropriate providers and educators who may receive a consultation include the following:

Home health care agencies
Child care providers
Children’s mental health case managers
Educators
Probation agents
Adoption or guardianship workers
Guardians ad litem
Child protection workers
Pediatricians
Nurses
After-school program staff
Mentors

Consultations are about:

Issues about the child's symptoms
Strategies for effective engagement, care and intervention needs
Treatment expectations across service settings
Clinical service components provided to the child and family

Clinical care consultation requires that :

the child has a diagnosis of mental illness determined by a diagnostic assessment that
meets the definition of complex, as defined in the Minnesota Rules 9505.0372, Subpart 1, C, or co-occurs with other complex and chronic health conditions, and
Requires consultation to other providers working with the child to effectively treat the condition, and
that the medical necessity for clinical care consultation is identified in the child's Diagnostic Assessment.

You may provide care consultation in person or by telephone.

Explanation of Findings

Helpful Tips:

Use Explanation of findings to:

Explain the results and recommendations from a Diagnostic Assessment to an adult or child, family members, and other caregivers for adults.
Explain your Diagnostic findings and recommendations as it pertains to a medical opinion, or reasonable accommodation form requested by a person you have diagnosed.

Explanation of findings" means the explanation of a client's diagnostic assessment, psychological testing, treatment program, and consultation with culturally informed mental health consultants as required under parts 9520.0900 to 9520.0926, or other accumulated data and recommendations to the client, client's family, primary caregiver, or other responsible persons.

The purpose of explanation of findings is to discuss the results of the diagnostic assessment, psychological tests, and other accumulated data and make recommendations in regard to the recipient’s treatment plan.

Explanation of Findings is a face-to-face or telehealth service. You may provide up to two sessions of Explanation of Findings annually, and with some payers, up to four with prior authorization.

Family Psychoeducation

Family psychoeducation is a service to children and their families. It is charactarized by planned, structured and face-to-face interventions that involve presenting or demonstrating information. The goal of family psychoeducation is to help prevent relapse or development of comorbid disorders and to achieve optimal mental health and long-term resilience. It supports the recipient and family in understanding:

The recipient’s symptoms of mental illness
The impact on the recipient's development
Needed components of treatment
Skill development

Who are Family Members?

The recipient’s family includes people the recipient, parent or guardian identify as being important to the recipient's mental health treatment. Family may include, but is not limited to parents or caregivers, siblings, children, people related by blood or adoption, and people who are presently living together as a family unit.

Treatment Plan Required

When pscyhoeducation services are planned, they must be identified as medically necessary in the Diagnostic Assessment.

Include medically necessary Family Psychoeducation services, developed with goals and objectives as part of the child's Individual Psychotherapy Treatment Plan.

Clinical Consultation

At Accend, we provide two types of Clinical Consultation. The first is Consultation to Other Provider. This is a service we provide on request to other agencies and providers to advise, consult and educate them about how to successfully support adults and children with mental health and behavioral disorders. This consultation is typically provided through a contract with these organizations.

Clinical Consultation to a Primary Care Provider is a service that is billable through Minnesota Health Care Programs. Mental health professionals with LICSW or LMFT licenses may provide this service to an individual's physician or advanced practice nurse who provides primary care in a variety of specialties. We provide this upon request of the primary health care provider.

Clinical Support

Clinical Support includes all of the above, but also refers to the invaluable role of the mental health professional in supporting the quality and consistency of other services a person receives. This includes ARMHS, Case Management, CTSS and Behavioral Health Home services.

As the Diagnostician, or the Psychotherapist, for a person recieving one of these services you are the lead in assuring the clinical quality of the services provided. This includes:

Monitoring initial and long-term engagement in the services you recommnend in the DA
Reviewing practitioner work on assessment and treatment/service planning to assure that it is consistent with your recommendations and the priorities you have identified in the DA and during psychotherapy services
Reviewing progress and updates to assessments and plans
Consulting with individual providers on questions they may have, problem-solving and brainstorming to improve services or build on past success
Facilitating or participating in Recovery Team Meetings for individuals.

Rendering Medical Opinions

You may be asked to provide medical opinions you your role as a mental health professional. These may be opinions about a persons ability to work, and about a variety of reasonable accommodations. Accend has this strict policy on medical opinions:

We will offer time-limited opinions (up to 90 days) for individuals who are new referrals, only when disability or need for accommodation is inarguably clear.
We will offer ongoing medical opinions only for individuals who are engaged in at least one service with us, so that we can render the opinion from an informed perspective.

See how to document Medical Opinions as an add-on or stand-alone service below.

Documenting Clinical Professional Services

Use the following service types to document Clinical Professional Services:

*Find instructions for documenting Clinical Care Consultation and Psychoeducation in the Psychotherapy chapter of this manual.

Service Name	Use For	Counts Toward Target Time
Client Specific Clinical Supervising	Person-specific notes about clinical supervision provided to providers of services within the agency	Yes
Clinical Consultation Client Specific	For use by a non-licensed or non-supervising mental health trainee or therapist while consulting on a case with a practitioner or case manager.	No
Clinical Consultation to Other Provider	Contracted consultation services to other organizations.	Yes
Clinical Consult to Primary Care FtoF	Consultation to primary health care providers upon request.	Yes
Clinical Consult to Primary Care NonFtoF	Consultation to primary health care providers upon request.	Yes
Clinical File Note	Quick notes in a person's file relating to clinical concerns.	No
Clinically Supervised Client Specific	Practitioners documenting specific supervision discussions, findings and plans for persons served.
Clinical Review of PRCT Assmt & Tx Plan	Clinicians time spent reviewing assessment and planning documents for assigned individuals.	Yes
Clinical Supervisor Supervising Others Yes
DA Cancellation By Provider	Cancellation of a DA by the individual provider, because we are closed for inclement weather, or other reasons not attributable to the recipient.	No
DA Client Initiated Cancellation	Cancellation of the DA by the recipient. Missed appointments. No-call, no-show.	No
DA Interview	The Diagnostic Assessment Interview.	No – DA is a set total upon approval
DA Review/Approve	Review of a DA written by a Trainee.	No – DA is a set total upon approval
DA Write Up	Time spent writing the DA and related activites such as facilitating referrals to recommended services.	No – DA is a set total upon approval
Explanation of Findings	Licensed provider explaining findings of the DA to an adult and/or family members or other key support people.	Yes
Explanation of Findings by Trainee	Trainee explaining findings of the DA to an adult and/or family members or other key support people.	Yes
Explanation of Findings Child	Licensed provider explaining findings of the DA to a child and/or family members or other key support people.	Yes
Explanation of Findings Child by Trainee	Trainee explaining findings of the DA to a child and/or family members or other key support people.	Yes
Medical Opinion (as an add-on service)	Document each time you are asked to render a medical opinion during a DA interview, Explanation of Findings, or Psychotherapy with one of the following add-ons: Medical Opinion Rendered - you gave a medical opinion Medical Opinion Declined - you declined to offer a medical opinion because you did not have adequate information.	No
Medical Opinion (as a stand-alone service)	Document each time you are asked to render a medical opinion and this activity is not associated with another encounter.	No
Open for DA	Indicates you are available to complete a DA interview.	No
Psychoeducation Family without Recipient	Providing Family Psychoeducation to a Family when the child is absent.	Yes
Psychoeducation Family with Recipient	Providing Family Psychoeducation to a Family when the child is present	Yes
Screening, Brief Intervention, and Referral to Treatment (SBIRT)	See Instructions above.	Sometimes
Treatment Supervising Client Specific	Clinical Supervisor roviding Treatment Supervision specific to a client	Yes
Treatment Supervised Client Specific	Receiving supervision specific to a client	No

Links and Resources

Tap on the following links to learn more about DAs and Explanation of Findings in the Minnesota Health Care Program (MHCP) manual

Feedback and Questions on this Chapter

Questions, Feedback & Suggestions

Updates to This Chapter

February 6, 2023:

Explanation that the Extended DA has been eliminated per a notification from DHS (effective 10/18/22).

December 29, 2022:

References to the DA Update removed in response to 245I.

January 6, 2022:

Screening, Brief Intervention, and Referral to Treatment (SBIRT) guidance added.

February 13, 2023:

DA requirements updated, including whe we will conduct a DA update, and statutory reference changed to 245I.10.

August 10, 2024:

DA requirements updated. Language added to clarify when a new DA is required/not required for continuing services.

August 21, 2024:

DA requirements updated. More language added to clarify when a new DA is required/not required for continuing services.

September 4, 2024:

Added procedures to follow when determining that a new DA is required.

September 11, 2024:

Added explanation of Interactive Complexity.