heatherwinters
Expert
A patient came in for an initial eval with psychiatrist and sees our counselor. Patient came back to see psychiatrist on 10/09/09. Length of visit was 15 minutes. Modality of treatment was medication management checked. However, no psychotropics were managed or documented. If a patient is only evaluated as to whether or not they should take psychotropics, you cant bill a 90862 can you?
From what I understand the following is a 90862
The following must be documented to justify the medical necessity and use of 90862:
• Diagnosis of the patient
• Evaluation of disease process
• Medication prescribed
• Rationale for the changes in drug therapy, expected response
• Order and/or review of laboratory tests as appropriate
• Patient allergies as appropriate
• Any minimal supportive psychotherapy
• Patient education of potential risks, side effects and benefits
If there is no CC: on the note, I have vitals, documentation of symptom checklist, no exam just a session synopsis, a plan to return in 2 months, icd-9 dx.
How would you code? Ask for documentation of CC: then bill 99212? The session wasnt long enough to bill as psychotherapy code.
Thanks
Heather
From what I understand the following is a 90862
The following must be documented to justify the medical necessity and use of 90862:
• Diagnosis of the patient
• Evaluation of disease process
• Medication prescribed
• Rationale for the changes in drug therapy, expected response
• Order and/or review of laboratory tests as appropriate
• Patient allergies as appropriate
• Any minimal supportive psychotherapy
• Patient education of potential risks, side effects and benefits
If there is no CC: on the note, I have vitals, documentation of symptom checklist, no exam just a session synopsis, a plan to return in 2 months, icd-9 dx.
How would you code? Ask for documentation of CC: then bill 99212? The session wasnt long enough to bill as psychotherapy code.
Thanks
Heather