This was coded as a 90805 and passed an audit. It was done by a doctor tho, not "incident to". There was additional information in it...
Hope it helps
This 30-year-old patient was referred to me by the Portland office. He has two previous psychiatric admissions history, where he has shown some severe psychotic symptoms in context of his substance abuse, including over the counter caffeine and ephedrine pills. Previously has been on Zyprexa, as per his father who came along with him. Patient has been doing fairly well, but does not want to take combination of medication. In fact, he sporadically takes pills. Patient's history thoroughly reviewed with the patient and his father. Patient is now feeling somewhat depressed part of changing medications and using some THC again. Supportive psychotherapy and education done thoroughly. He denies any active auditory or visual hallucinations. No evidence of paranoia or other forms of delusional thought process. Patient denies any neurovegetative symptoms of depression. Denies any active suicidal/homicidal ideations, intent, plan. He is currently jobless, but has been looking for a job. He has been able to concentrate and focus well. He is currently residing with his mother. He has no relationship. Will discontinue Fluvoxamine, increase in Prozac 60mg am, Invega 6mg hs. Benadryl 25mg hs. Side effects discussed.