Wiki no dx

[cynthiaj54]

One of my pschyciatrists was asked to do an evaluation of a young girl in the hospital. Her evaluation states no dx. When I questioned her on this, she said there were no psych problems. She wants to bill 90801. What do I use as the dx? Should she just bill a consult with "worried Well" dx?
This has stumped me. Thanks for your help

 

[kevbshields]

What were the presenting symptom or signs? If that isn't available, what was the consultative question?

 

[cynthiaj54]

There was a family history of bipolar and suicide. She had demonstrated a flat affect during the hospitalization (for abscess), but had no symptoms at time of evaluation. ??

 

[deyoung]

What about V71.09? This is used when a mental Dx is suspected but after eval is found not to exist.

 

[dmaec]

i'd go with a worried well/feared complaint unfounded code. I wouldn't (WOULD NOT) attach any psychiatric/mental health code to this young lady, unless it specifically states some sort of "mental disorder/illness". and since the provider said "no dx".. that means, "no dx".

just my opinion.

 

[wyawn]

The payor also determines what code can be used for no diagnosis V71.09; what is the payor for this patient?

Wendy, CPC

 

[C.orona]

V71.09
Observation for suspected condition is the best choice.

 

[walosi24]

Reason for the visit

I would suggest if there is no psychiatric diagnosis in AXIS I and II. I would use V71.09 as the primary diagnosis and code the reason for the visit as the secondary diagnosis. This is stated in the AF MH coding handbook. In the civilian world it may be the other way around because of payor guidelines.

I would go back to the doctor who ordered the consult to ask if he/she could share some more light on the subject. Family HX? Disease process? Medication? Several factors? I'll bet there is more to the story that did not appear in the notes. Maybe you would need more that two codes to tell the story so to speak. Hope this helps.