Scenario:
Let's say a client comes in for an office visit. It is determined that the client's one chronic psychiatric condition is stable. For example: 296.32 Major Depressive Disorder, Recurrent, Moderate-stable
The physician states that the Major Depressive disorder is causing 4 problem points of treatment (depression, anxiety, insomnia and irritability) each “problem” documented as stable.
Problem #1: Depression (improving)
Continue Cymbalta 60 mg daily (30-day supply, 2 refill).
Continue Wellbutrin XL 300 mg daily (30-day supply, 2 refill).
The patient is currently in the process of completing psychotherapy
Problem #2: Anxiety (stable)
Continue Klonopin 0.5 mg twice daily (30-day supply, 2 refill).
Problem #3: Irritability (stable)
Continue Lamictal 150 mg daily (30 day supply - 2 refills).
Problem #4: Insomnia (stable)
Continue trazodone 50 mg at bedtime (30 day supply - 2 refills).
Questions:
1.) When assigning points for “number of diagnoses or management options” would the physician get credit for all 4 of the stable “problems” (4 pts)?
2.) When determining “Risk” would the level be Moderate based on “Two or More Stable Chronic Illnesses “? [/SIZE]
Let's say a client comes in for an office visit. It is determined that the client's one chronic psychiatric condition is stable. For example: 296.32 Major Depressive Disorder, Recurrent, Moderate-stable
The physician states that the Major Depressive disorder is causing 4 problem points of treatment (depression, anxiety, insomnia and irritability) each “problem” documented as stable.
Problem #1: Depression (improving)
Continue Cymbalta 60 mg daily (30-day supply, 2 refill).
Continue Wellbutrin XL 300 mg daily (30-day supply, 2 refill).
The patient is currently in the process of completing psychotherapy
Problem #2: Anxiety (stable)
Continue Klonopin 0.5 mg twice daily (30-day supply, 2 refill).
Problem #3: Irritability (stable)
Continue Lamictal 150 mg daily (30 day supply - 2 refills).
Problem #4: Insomnia (stable)
Continue trazodone 50 mg at bedtime (30 day supply - 2 refills).
Questions:
1.) When assigning points for “number of diagnoses or management options” would the physician get credit for all 4 of the stable “problems” (4 pts)?
2.) When determining “Risk” would the level be Moderate based on “Two or More Stable Chronic Illnesses “? [/SIZE]