Wiki Behavioral Health Cdoing-supporting documentation


Best answers
I code for a multi specialty physician group and we are starting a behavioral health dept. They are asking me to code these visits (90801-90814) but denying me access to the charts citing that there is a legal mandate regarding this. How can I code these visits when I can't read their dictation? Does anyone else have this issue? Wouldn't Medicare have access if we got audited? How do we comply with this new "law" and still code accurately?
Any insight regarding this would be greatly appreciated... please and thanks!
You are kidding?

What legal mandate are they talking about? What new law are they referring to? I have never heard of this. Are you working in the office? are you coding the diagnosis as well? The gov can come in and audit anytime they want to. Yes, Medicare will have access to the charts. Confidentiality is vital in mental health, but the coder should have access to the chart to code correctly. I have been working in mental health for 14 years and never heard of this.
Yes I work in the coding office of the same building as these providers and yes I will be coding the dx. We share an electronic medical record but they have it restricted so that no one can view it. I asked them to provide the "legal mandate" to me as well and haven't gotten it yet. I am wondering if this is just their interpretation, more of a provider preference than an actual legal mandate. I had never heard of it before nor have any of the other coders I had talked to. I understand confidentiality is key but I don't know how to code accurately without access. I wish I had something in black and white to support my argument. Thanks so much for responding. I appreciate the input and welcome any advice you may have.
Coding for Mental Health

I too work for a multispecialty practice and one of the services we offer is mental health. I have access to these records. We do have some staff who are restricted from seeing these types of notes but since my job deals specifically with coding based on documentation I have access. If they do not provide you with access to the notes, you cannot code the visit. I have heard of other practices where coders are not allowed access to the records, however, in those settings - the provider is taking full responsibility for the coding of the service.

Here is a good publication that deals with confidentiality and Mental Health Records and it offers a phone number on how to obtain additional information. Since your job deals with evaluation of the record for the purpose of obtaining payment - I would think your employer should be covered in allowing you access. Again, i would obtain clarification
Last edited: