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Question Mental Status Exam-Where Does It Belong?

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dballard2004

dballard2004

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I am having a conflict with a provider about psychotherapy and an E/M service. The issue lies with where the mental status exam should be documented. I say it belongs as part of the psychotherapy; the provider says it should be part of the E/M. I have searched guidance from CMS, but I'm unable to find any specific guidance. Any thoughts?
 
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At the behavioral health facility where I work, we consider it part of the E&M based on the '97 specialty E&M guidelines for psychiatry. I have never seen any reference in the new E&M guidelines that this is not an acceptable part of the E&M service in lieu of the standard medical exam.
 
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