Need code for Psychiatric consultation

[banumathy]

Hi All,

I am very new to the psychiatric coding, please help me to code below document.

I have received document stating "Psychiatric consultation report"

document look like normal E/M document,

for History- cc, HPI, hx, ROS- has documented

for Exam- mental status exam was done(General appearence, speech, mood/affect, memory, sensorium/orientation, hallucination, language, homicidal & sucidal ideation, calculation ability, thought process, HEENT, musculo/skeltal)

lab studies had done.

Kindly advice what CPT code should be used for above document, however timing also not given.


Advance thanks to all,

Banu, CPC

 

[Pam Warren]

If your provider is a psychiatrist and not a psychologist, then you can code an E&M visits, but you would need to meet the criteria for a consultation in order to bill such a code. CPT has changes in 2010, but basically, request, opinion and report still apply. Based on what little information you've given, I can't suggest a level of service from an auditing perspective. Is there a detailed history documented? Problem focused exam? Without seeing the entire note, I can't recommend any code, sorry.

If your provider is a psychologist, you'll have to report a diagnostic interview, 90801

 

[smdumpert]

Have you considered using 90801? Without seeing the documentation I can't say for sure. In my area of the country, the code can be used by Psychiatrist, Psychologist and LCSW's.

 

[Basil]

ED coder

I also use 90801...as Sara...