inpatient psychiatric facility guidance

esexton

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Hey there! I am currently(for 2 months) a coding associate in an inpatient psychiatric hospital. The facility is the only one in my state that actually uses certified coders and has only been doing so for around 4 years at most. Unfortunately, there is very limited information on correct coding for inpatient psychiatric. I am having a very difficult time finding a good instructional template for E/M coding initial/subsequent hospital care. The ones that i have seen are geared toward regular inpatient hospital care with the guidance offered only pertaining to physical illnesses. The coding lead unfortunately has only been a practicing coder for 3-4 years with this facility being the only coding experience. My previous coding experience was in a large outpatient clinic/provider office base. I would greatly appreciate any guidance available or a point in the best direction to locate resources to ensure that i am practicing correct coding. Thanks in advance for any advice
 

ckeeney

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For inpatient/outpatient psychiatric E/M coding, use the 1997 Documentation Guidelines specialty template for determining levels for each component. Then use the CPT code guidelines for service level. There is a lot of information on the American Psychiatric Association and the American Academy of Child & Adolescent Psychiatry websites as well as MLN documents from CMS. Check your state Medicaid guidelines for their specific rules.
 

esexton

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thanks

Thank you for the info. Without a more knowledgeable lead it has been very difficult to get a handle on making sure i am choosing the correct e/m code. And it'd be great to stumble on a really good documentation template to get the drs in line with proper documentation that would greatly assist with choosing correct codes also.
 
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