Wiki Mental Status Exam - Bullet Points

[donaldjr1969]

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!

 

[Pam Warren]

Good question, and you're not a noob anymore if you're asking questions like this one!

Well, I poked around in the 97 guidelines to see if there was any clarification with regards to your question. Because detailed and comprehensive exams require that you meet the bulleted items as they are written, and because all other coding conventions that indicate "AND" does not mean "and/or" unless specifically noted, I'd wager that you do need to satisfy documentation for both mood and affect to get credit for that bullet.

 

[donaldjr1969]

Thank you, Pam. My original line of thought was due to the fact that one seems to support the other. Meaning mood leads to affect and that affect is upon what a provider makes a judgment. Same with insight and judgement. I thought that judgment results from insight and that if insight is noted, then their judgment has to be considered to arrive at their judgment.

In my reply to my coworker, I did say that it may be a good idea to reference both regardless of requirements. And to be honest, well over 90% of my chart notes that I code do indeed reference both halves.

I realize coding is something one will never truly master...especially with it changing all the time! Just when we think we have the answers, CMS, AMA, etc all change the questions! But I just want to be on top of things as best as I can so that if we ever have an adversarial audit, we will be fully prepared to provide documentation to support our original coding.