SUD COUNSELOR HANDBOOK  
                 WITH DOCUMENTATION GUIDELINES 
                                   
                             VERSION 3A 
                                   
                            September 2020 
                                   
                    Orange County Health Care Agency 
                        Behavioral Health Services 
                         
                     Contents 
                     1.    Introduction ..................................................................................................................................... 5 
                     2.    Medical Necessity............................................................................................................................ 5 
                        ASAM & Levels of Care ..................................................................................................................... 6 
                        Scope of Practice ................................................................................................................................. 8 
                     3.    Initial Assessment ............................................................................................................................ 9 
                     4.    Treatment Plan .............................................................................................................................. 16 
                        Statement of the Problem ................................................................................................................... 17 
                        Statement of the Goal ........................................................................................................................ 17 
                        Action Steps ...................................................................................................................................... 18 
                        Target Dates ...................................................................................................................................... 19 
                     5.    Continuing Services Justification & Treatment Plan Review .......................................................... 20 
                     6.    Progress Notes ............................................................................................................................... 23 
                        OTHER COMPONENTS OF A PROGRESS NOTE: ........................................................................ 25 
                     7.    Codes & Services........................................................................................................................... 26 
                        Withdrawal Management (WM) ........................................................................................................ 27 
                           Billing Codes ................................................................................................................................. 27 
                        Medication Assisted Treatment (MAT) .............................................................................................. 27 
                           Billing Codes ................................................................................................................................. 27 
                        Narcotic Treatment Programs/Opioid Treatment Programs (NTP/OTP) ............................................. 27 
                           Billing Codes ................................................................................................................................. 27 
                        Recovery Services ............................................................................................................................. 27 
                           Billing Codes ................................................................................................................................. 27 
                        Individual Counseling ........................................................................................................................ 28 
                           Billing Codes ................................................................................................................................. 28 
                           Assessment .................................................................................................................................... 29 
                           Crisis Intervention ......................................................................................................................... 32 
                           Treatment Planning ........................................................................................................................ 33 
                           Collateral ....................................................................................................................................... 34 
                           Family Therapy ............................................................................................................................. 34 
                           Billing Codes ................................................................................................................................. 34 
                           Individual Counseling .................................................................................................................... 35 
                           Discharge Planning ........................................................................................................................ 36 
                                                                                        
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                        Case Management ............................................................................................................................. 37 
                           Billing Codes ................................................................................................................................. 37 
                        Group Counseling .............................................................................................................................. 40 
                           Billing Codes ................................................................................................................................. 40 
                        Billing ............................................................................................................................................... 43 
                           NON-BILLABLE SERVICES: ...................................................................................................... 43 
                           NON-COMPLIANT SERVICES ................................................................................................... 44 
                           Time Reminders ............................................................................................................................ 44 
                     8.    Discharge Summary ....................................................................................................................... 44 
                     9.    Documentation Examples .............................................................................................................. 46 
                     10.      Appendix ................................................................................................................................... 48 
                        Appendix A: Substance Use Disorder Diagnoses DSM-5 Criteria Guide ............................................ 48 
                        Appendix B: ASAM Criteria Dimensions and Rationale Worksheet ................................................... 49 
                        Appendix C: Documenting Impairments Related to SUD Guide ......................................................... 50 
                        Appendix D: What Needs to be in The Case Formulation? ................................................................. 51 
                        Appendix E: Billing Assessment and Re-Assessment Activities ......................................................... 53 
                        Appendix F: Treatment Plan Reference Sheet .................................................................................... 55 
                        Appendix F: What are SMART goals? ............................................................................................... 57 
                        Appendix G: Treatment Plan Checklist .............................................................................................. 58 
                        Appendix H: Sample Treatment Plan ................................................................................................. 59 
                        Appendix I: Sample SUD Re-Assessment (Continuing Services Justification) .................................... 62 
                        Appendix J: SUD Progress Note Checklist ......................................................................................... 67 
                        Appendix K: Progress Note Elements ................................................................................................ 68 
                        Appendix L: Documentation Language by Service Type .................................................................... 69 
                        Appendix M: Sample Discharge Plan ................................................................................................. 70 
                        Appendix N: Sample Discharge Summary ......................................................................................... 71 
                      
                      
                      
                      
                      
                                                                                        
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