donaldjr1969
Contributor
Good morning.
Earlier today, a coworker came to me with regards to documentation required for credit to a bullet point on a mental status exam. The specific question dealt with those points that contain AND in them, such as insight AND judgment or mood AND affect. The specific question is does the provider need to reference both insight and judgment to get credit for that point? Or can I still consider that bullet point if only one part has been documented such as mood but not affect, judgment but not insight, etc?
Granted I am still a noob at coding having been certified in July 2012 and been permanently hired to my current job on Jan 2013. But my guess is that both do not have to be referenced to get credit for that bullet point. Am I correct in that or do the providers have to reference both parts in order to get credit for that when it comes down to coding the encounter?
I appreciate any assistance you can give me!
Earlier today, a coworker came to me with regards to documentation required for credit to a bullet point on a mental status exam. The specific question dealt with those points that contain AND in them, such as insight AND judgment or mood AND affect. The specific question is does the provider need to reference both insight and judgment to get credit for that point? Or can I still consider that bullet point if only one part has been documented such as mood but not affect, judgment but not insight, etc?
Granted I am still a noob at coding having been certified in July 2012 and been permanently hired to my current job on Jan 2013. But my guess is that both do not have to be referenced to get credit for that bullet point. Am I correct in that or do the providers have to reference both parts in order to get credit for that when it comes down to coding the encounter?
I appreciate any assistance you can give me!