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Quite frequently patients of our medical clinic will be referred to our LCSW to discuss any issues that may have come up during an office visit. ie: domestic abuse.
An example note from our LCSW:
ACTION TAKEN: LCSW met with pt. at request of Dr. _______. She is accompanied by two of her young daughters and a male friend whom she describes as supportive. After friend left exam room, LCSW inquired as to past history of domestic violence with her two year old daughter's father. Although she denies current domestic violence, she does have concerns about his controlling behavior and is agreeable to have counseling through Safe Haven's program. LCSW gave her information on how to make contact with Safe Haven. LCSW to follow as needed.
I can attach an ICD-9 of V62.89 as seen below.
A snippet from the (seperate) Physician note:
V62.89-STRESS LIFE CIRCUMSTANCE (REASON FOR ENCOUNTER) Had LCSWb meet with patient re difficulties with previous abuser (see her note.)
If your opinion is not codeable...what documentation would you suggest?
Thank you for checking this out!
An example note from our LCSW:
ACTION TAKEN: LCSW met with pt. at request of Dr. _______. She is accompanied by two of her young daughters and a male friend whom she describes as supportive. After friend left exam room, LCSW inquired as to past history of domestic violence with her two year old daughter's father. Although she denies current domestic violence, she does have concerns about his controlling behavior and is agreeable to have counseling through Safe Haven's program. LCSW gave her information on how to make contact with Safe Haven. LCSW to follow as needed.
I can attach an ICD-9 of V62.89 as seen below.
A snippet from the (seperate) Physician note:
V62.89-STRESS LIFE CIRCUMSTANCE (REASON FOR ENCOUNTER) Had LCSWb meet with patient re difficulties with previous abuser (see her note.)
If your opinion is not codeable...what documentation would you suggest?
Thank you for checking this out!