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ggparker14

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Can I get some opinions on the number of elements that this ER note contains?

Note reads: pt. presents for volunteer psych admission for depression and SIS. The pat. has insurance and wants to be admitted. Wants to hurt self. Has been in psych facility before.

Thanks for any help.
 
rhblevins61@yahoo.com said:
Can I get some opinions on the number of elements that this ER note contains?

Note reads: pt. presents for volunteer psych admission for depression and SIS. The pat. has insurance and wants to be admitted. Wants to hurt self. Has been in psych facility before.

Thanks for any help.
Click to expand...

Has insurance...lol - Nice focus on the important stuff...:rolleyes:

I see a chief complaint of depression
Associated sign - SIS
Quality or Severity - wants to hurt self
Past History - Has been in psych facility before.
1 ROS for psychiatric
Overall History = EPF

Although, from the sound of it, I should advise you that if the doctor thought the pt was full of crap, the medical necessity of a mid-high level code may not be warranted. Hope that helps! ;)
 
btadlock1 said:
Has insurance...lol - Nice focus on the important stuff...:rolleyes:

I see a chief complaint of depression
Associated sign - SIS
Quality or Severity - wants to hurt self
Past History - Has been in psych facility before.
1 ROS for psychiatric
Overall History = EPF

Although, from the sound of it, I should advise you that if the doctor thought the pt was full of crap, the medical necessity of a mid-high level code may not be warranted. Hope that helps! ;)
Click to expand...

"should advise you that if the doctor thought the pt was full of crap"

HUH??? Hopefully the ER doctor is wise enough not to judge this patient and allows an expert to take care of the situation.

If properly documented suicidal ideation can be coded as a 99285.
 
DeeCPC said:
"should advise you that if the doctor thought the pt was full of crap"

HUH??? Hopefully the ER doctor is wise enough not to judge this patient and allows an expert to take care of the situation.

If properly documented suicidal ideation can be coded as a 99285.
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"pt. presents for volunteer psych admission for depression and SIS. The pat. has insurance and wants to be admitted. Wants to hurt self. Has been in psych facility before."

That's what's documented. I don't detect much concern, although I've been mistaken before. Medical necessity is derived primarily from the information in the HPI. I disagree that this particular HPI indicates a high enough level of medical necessity to justify a high level E/M, such as 99285; besides, it falls short of the requirements. The highest ED E/M that can be achieved is 99283, with this history, and that's assuming the exam and MDM stack up.
 
I said, "If properly documented suicidal ideation can be coded as 99285." In other words, suicidal ideation is a high risk medical issue and satisfies medical necessity---elements of an HPI is a whole other subject. Lack of documentation does not determine medical necessity it determines what e/m you can code.

Sometimes an ED note's documentation is better in the plan than in the HPI. Psych issues in the ED are usually not handled by the ED doctors (at least that has been my coding experience 5 years of coding ED and >8yrs inpt)
 
DeeCPC said:
I said, "If properly documented suicidal ideation can be coded as 99285." In other words, suicidal ideation is a high risk medical issue and satisfies medical necessity---elements of an HPI is a whole other subject. Lack of documentation does not determine medical necessity it determines what e/m you can code.

Sometimes an ED note's documentation is better in the plan than in the HPI. Psych issues in the ED are usually not handled by the ED doctors (at least that has been my coding experience 5 years of coding ED and >8yrs inpt)
Click to expand...

Well, it's not properly documented, so this time, it doesn't. Case closed.
 
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