medicalauditor
Networker
I am looking for detailed documentation requirements for 90791 - Psychiatric diagnostic evaluation. The CPT code book does not really elaborate on what should be documented. I can't find anything from CMS either. I did find a fact sheet by CGS which states that the following must be documented:
• Elicitation of a complete medical and psychiatric history (including past, family, social)
• Mental status examination
• Establishment of an initial diagnosis
• Evaluation of the patient’s ability and capacity to respond to treatment’
• Initial plan of treatment
However, we have Novitas in Texas, and I can't find anything from them. I would appreciate it if someone can help with a CMS resource or any other MAC. I am looking specifically for documentation requirements which state that complete history including FAMILY and SOCIAL history must be documented, and a MSE, as stated by CGS. Our providers don't document family and social history and don't document a detailed mental status exam - they just document "within normal limits" which I feel is not sufficient. If I just quote the CGS resource, there will be pushback, so I am looking for CPT, AMA, CMS or any other valid resource. Thank you!
• Elicitation of a complete medical and psychiatric history (including past, family, social)
• Mental status examination
• Establishment of an initial diagnosis
• Evaluation of the patient’s ability and capacity to respond to treatment’
• Initial plan of treatment
However, we have Novitas in Texas, and I can't find anything from them. I would appreciate it if someone can help with a CMS resource or any other MAC. I am looking specifically for documentation requirements which state that complete history including FAMILY and SOCIAL history must be documented, and a MSE, as stated by CGS. Our providers don't document family and social history and don't document a detailed mental status exam - they just document "within normal limits" which I feel is not sufficient. If I just quote the CGS resource, there will be pushback, so I am looking for CPT, AMA, CMS or any other valid resource. Thank you!