Documentation Is Crucial in Supporting Psych E/M Level
Published on Sat Sep 01, 2001
Primary psychiatric visits to the ED are common. However, the acutely suicidal or psychotic patient can be a challenge to the ED physician and coder. Acute cases can usually be coded 99285 (emergency department visit for the evaluation and management of a patient ...) because the patient's psychiatric illness typically poses a threat to life or bodily function. But the physician must clearly document all the elements required to support a level-five service.
"Many psychiatric visits are from chronic 'frequent fliers' who, after careful screening and medication refills, can be released," says Michael Granovsky, MD, chief financial officer of Greater Washington Emergency Physicians, a five-physician ER staffing group in Maryland. "However, level-five cases require an extensive workup and thorough documentation, and these cases often result in the need to admit the patient."
Initially, the physician screens for metabolic/organic causes to determine if this contributes to an acutely suicidal or psychotic patient's decompensation. This usually involves a complete history -- both medical and psychiatric -- and a physical exam.
"It would not be uncommon for the history to be in-depth and satisfy 1995 guidelines for 99285," Granovsky says. "Certainly an exam of eight organ systems would also be common, also satisfying 99285. The medical decision-making (MDM) is generally felt to be moderate and could be coded 99284 (emergency department visit for the evaluation and management of a patient ...). If there are additional complicating factors, such as chest pain or acute mental-status changes, these cases may be elevated to 99285."
Scenario: Police bring a 48-year-old female to the ED after she is found wandering in traffic. She appears to be responding to internal stimuli and on further questioning is withdrawn, but she admits to hearing voices. She has given no indication of plans to hurt herself, but her thoughts are very disorganized and her responses are frequently inappropriate. Her past medical history is obtained from the family via phone, and they report she has a long history of schizophrenia (295.xx) and substance abuse (305.xx) and sometimes decompensates, but never to this extent.
She has been off her medication for some time. The physician gathers a complete history by speaking with the family. A full physical exam is performed, which yields a finding of a swollen left wrist (729.81) and a large occipital hematoma (920). Based on her severe agitation (307.9), the doctor administers IV Haldol and performs screening labs for the metabolic causes of her agitation. Wrist x-rays are taken, and to rule out a subdural hematoma the patient receives a head CAT scan.
Her lab results, head CAT scan and wrist x-rays come back normal. Her agitation is controlled with frequent doses of Haldol and Ativan. Because the current hospital does not have inpatient [...]
