Psychiatry Coding & Reimbursement Alert

Published on Thu Dec 12, 2013 PDF

Question: I am new to psychiatry coding. As psychiatry coding is now allowing the use of evaluation and management codes, can you please tell me what are the components of a psychiatry-specific review of systems? Can a psychiatry ROS qualify for a problem-focused examination?

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Answer: From a CPT® and evaluation and management documentation perspective, a review of systems (ROS) is an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms that the patient may be experiencing or has experienced.

For purposes of ROS, the following systems are recognized:

• Constitutional Symptoms (e.g., fever, weight loss)
• Eyes Ears, Nose, Mouth, and Throat
• Cardiovascular
• Respiratory
• Gastrointestinal
• Genitourinary
•  
• Musculoskeletal
• Integumentary (skin and/or breast)
• Neurological
• Psychiatric
• Endocrine
• Hematologic/Lymphatic
• Allergic/Immunologic

From this perspective, there is no psychiatry specific ROS unless you mean one that only inquired about the patient’s psychiatric system. An ROS that only inquired about the psychiatric system would be problem-pertinent which may support up to an expanded problem-focused level of history.

In terms of examination, there is a psychiatric system examination specified in the 1997 version of the E/M documentation guidelines. Depending on the number of elements that are done and documented, it may cover anything from a problem-focused to a comprehensive examination.

Specific to the psychiatric system portion of the psychiatric system examination, the documentation guidelines list the following components:

• Description of speech including rate, volume, articulation,
• coherence, and spontaneity, with notation of abnormalities (e.g., perseveration, paucity of language)
• Description of thought processes including rate of thoughts, content of thoughts (e.g., logical versus illogical, tangential), abstract reasoning, and computation
• Description of associations (e.g., loose tangential, circumstantial, intact)
• Description of abnormal psychotic thoughts, including hallucinations, delusions, preoccupation with violence, homicidal or suicidal ideation, and obsessions
• Description of patient’s judgment (e.g., concerning everyday activities and social situations) and insight (e.g., concerning psychiatric condition)

It also lists a complete mental status examination of the patient, including the following components:

• Orientation to time, place, and person
• Recent and remote memory
• Attention span and concentration
• Language (e.g., naming objects, repeating phrases)
• Fund of knowledge (e.g., awareness of current events, past history, vocabulary)
• Mood and affect (e.g., depression, anxiety, agitation, hypomania, lability)