Wiki Behavioral Health diagnosis/documentation

Saddleup31

Guest
Messages
9
Best answers
0
I'm hoping I could get some suggestions for knowledge references. I'm looking for Mental Health guidance for coding. I've coded for many years, but not in the mental health field. I'm learning from my providers that they feel the general medical documentation is different than psychiatric documentation. Any help would be greatly appreciated. thank you in advance.
 
For the psychiatric E&M visits we use the 1997 specialty guidelines. For general coding and documentation guidelines the American Psychiatric Association has some resources if you have access. Also Medicare has a mental health manual (our state Medicaid - Indiana - does too). AAPC has a behavioral health course but no credential. When searching for information you often have to use behavioral health, mental health, or psychiatry.
 
Thank you so much. Right now I'm getting kick back on documentation of medications with diagnosis. I know guidelines, but being told they are different for BH. ?? TYIA
 
I worked in mental health for more than a dozen years, and I do not know a single psychiatrist, psychologist, licensed clinical social worker or marriage and family counselor who does not select their own diagnoses. Procedures are easy; the diagnoses, not so much.

What kind of problems are you having?
 
I'm asking for diagnosis to support New scripts written, and I'm told they don't need to assign or attach a diagnosis. Its a Medical field thing, not psych ? I thought compliance was compliance so I'm looking for guidelines that break it down to show them or for me to learn different, if that is the case.
 
Every prescription, every treatment, every surgery, everything a provider does for a patient should have a documentation of medical necessity. This includes a prescription. If they are writing for controlled substances, then a lot of pharmacies will not fill them without a diagnosis.

I am on the mailing list for the Medical Board in my state. Weekly, I get emails showing what actions the Medical Board is taking against doctors. I randomly read through the documents to see where the Medical Board is finding fault, and to make sure we are not committing any of those same errors. A very big problem relates to documentation. The doctor may have talked about it with the patient, but if it's not documented, it never happened. If a doctor prescribes, for example, xanax, but there is no documentation or diagnosis of anxiety, they have an accusation filed against them for not following standard of care, not having adequate documentation, prescribing controlled substances without documented medical necessity, etc.

Some electronic medical records make this easy for you. The ones that I like that I have seen will have each diagnosis, and then the plan for that diagnosis. For instance:

1. Major Depression, Recurrent, Moderate (F33.1)
- Prozac, 40 mg, 1 po qd, #30 for 30 days.​
- Continue psychotherapy twice monthly with psychologist.​
- Return in 30 days.​
2. Anxiety Disorder (F41.1)
- Xanax, 0.5mg, 1 po q8h prn anxiety, #90 for 30 days.​
- Practice daily meditation (see handout given to patient).​
- Return in 30 days.​

Contrast that to:

Assessment: Major Depression F33.1
Plan: Prozac 40 mg 1 po qd, #30 for 30 days; Xanax 0.5 mg, 1 po q8h prn anxiety, #90 for 90 days; Adderall 20 mg, 1 po bid #60, Nuedexta 20/10mg, 1 po qd #30, return in 30 days.

Xanax? No one said anything about anxiety.
Adderall? No one said anything about attention deficit issues.
Nuedexta? Where does it say the patient has pseudobulbar affect??
 
Last edited by a moderator:
EXACTLY! THANK YOU!!!!! I'm going to stick with the knowledge that I know then!! I'm just going to continue with examples and the whys. I continue to state "if it isn't documented, it didn't happen. and If its pulled in an audit that is not good. Do you believe I'm asking too much by asking specifically for the diagnosis given prior, instead of in the plan stating the medication is for "mood". "I've been told well its assumed its for the depression, why do I have to say Depression ?" thank you so much for your opinion. I need someone else to tell me I'm not crazy . a person starts questioning themselves.
 
EXACTLY! THANK YOU!!!!! I'm going to stick with the knowledge that I know then!! I'm just going to continue with examples and the whys. I continue to state "if it isn't documented, it didn't happen. and If its pulled in an audit that is not good. Do you believe I'm asking too much by asking specifically for the diagnosis given prior, instead of in the plan stating the medication is for "mood". "I've been told well its assumed its for the depression, why do I have to say Depression ?" thank you so much for your opinion. I need someone else to tell me I'm not crazy . a person starts questioning themselves.

"Mood" is not a diagnosis, and they should know better. You can assume nothing. Even the "Bad News Bears" knew that.
 
Top