How should the following note be billed? The psychiatrist wants to report the med managment (code 90863 and of course Q3014 for telehealth) but what is the primary procedure? Do we report an E/M code with this? Any and all advise most appreciated!!
Patient came to the office for a behavioral health visit.
Nursing Staff:
Patient assisted by MA.
Vital Signs:
Time: 11:05 AM
Weight: 172 lbs
Height: 66"
BMI: 27.76
Temperature: 97.0 F
BP: 120/72(Left Arm)(Sitting)
Pulse: 72(Left radial)(Sitting)(Regular)
Respiration: 16
Chief Complaint:
Patient is here to follow-up from Behavioral Health visit.
Current Medication:
1 Zyprexa Zydis 20 Mg Tablet Take 1 tab under the tongue daily
2 Lorazepam 2 Mg/ml Oral Concent Take 0.5mL BID
3 No Otc Meds. (OTC)
1/11/13 Pt has not started Lorazepam; will to discuss with provider
Allergy/Adverse Reaction:
No Known Drug Allergies
Social History:
Social history reviewed and unchanged on Jan 11, 2013 by, MA.
Patient has never smoked or used tobacco products.
He denies alcohol use.
He denies recreational drug use.
Patient is divorced.
Caffeine intake consists of He denies drinking caffeinated coffee., He denies drinking caffeinated soda., He denies drinking caffeinated tea. He denies exposure to 2nd hand smoke.
Family History:
Family history reviewed and unchanged on Jan 11, 2013 by, MA. Family history unremarkable.
Medical History:
Reviewed and unchanged on Jan 11, 2013: allergies, current medication list, medical history, immunizations, by, MA.
He has not been hospitalized or visited the ER in the last 12 months. Specialist(s) seen: Psychology-Psychiatry:xxx
Schizophrenia.
Surgeries- Procedures: No surgical history.
HPI:
Patient presents to xxx and office visit conducted with psychiatrist via Telehealth.
Patient did not endorse symptoms of persistently elevated mood, inflated self-esteem or grandiosity, increased interest in goal-directed activitiies, lack of sleep or need for sleep, distractibiltiy or disinhibited behavior, (e.g. excessive spending, sexual indiscretion) to suggest mania/hypomania.
PSYCHOSIS: Presents with features consistent with psychosis, including: delusions, no hallucinations, thought withdrawal or insertion.
The pt with catatonic schizophrenia. He continus to do well. Admits having some twitching of his arm last wk. Informed the dad about the risk of tardive diskinesia with antipsycotics. The pt is sleeping well, eating well. not catatonic anymore. He still have baseline delusion, but no obvious delusion or psychosis noted.
ROS:
Current medications reviewed. Past medical history, family history, and social history reviewed.
Mental Status Exam:
Appearance: Dressed casually. Well groomed. Good rapport and good eye contact. Behavior: No psychomotor agitation or retardation noted. Not observed to respond to hallucinations. Speech: Spontaneous, comprehensible, and normal in rate, rhythm, and volume. Mood: Patient describes mood as "okay". Affect: Affect is restricted, poor eye contact. Thought Process: Thought process observed to be at times not longical. Thought Content: Patient has delusions of. Patient denies any homicidal ideas. Patient denies any suicidal ideas. Perception: No hallucinations in any sensory modality. Insight: Intact. Patient understands illness, and seeks help appropriately. Patient is alert and oriented in time, place, and person.
Diagnosis:
295.2 Catatonic Schizophrenia
Prescription:
Refill Added:
(1) Zyprexa Zydis 20 Mg Tablet 2 time(s)
Care Plan:
Patient is not imminently suicidal, homicidal, floridly psychotic, or unable to care for self, and therefore does not require urgent in-patient care/intervention. Patient advised to go to the nearest emergency room or call 911 if suicidal or homicidal or experiencing a severe deterioration in his mental health. 24 Hour Mental Health Crisis Lines. Supportive counseling offered. Encouraged to continue with or seek individual counseling/therapy. Discussed treatment options including the option of no treatment and discussed risk versus benefits. Discussed side effects and adverse effects of all newly prescribed medications, and offered printed patient information material on newly prescribed medications. Advised to avoid use of machinery or driving until sure how medications affect/assess drowsiness. Patient also warned of the potential for suicidal ideation or an increase in SI occuring with SSRI and has been advised to adhere to the safety advise as listed below. Follow-up with primary care provider with any health care concerns. Advised to stay away from alcohol and illegal substances. Recommend patient be seen by a Behavioral Health provider (psychologist or Licensed Clinical Social Worker). Follow-up with Dr. X in 2 month(s).
The pt continus to do well, not catatonic anymore.
-- Continue Zyprexa 20mg daily
-- Continue atian 1mg bid prn
-- Need basic labs next visit.
This visit note has been electronically signed off by following providers.
Patient came to the office for a behavioral health visit.
Nursing Staff:
Patient assisted by MA.
Vital Signs:
Time: 11:05 AM
Weight: 172 lbs
Height: 66"
BMI: 27.76
Temperature: 97.0 F
BP: 120/72(Left Arm)(Sitting)
Pulse: 72(Left radial)(Sitting)(Regular)
Respiration: 16
Chief Complaint:
Patient is here to follow-up from Behavioral Health visit.
Current Medication:
1 Zyprexa Zydis 20 Mg Tablet Take 1 tab under the tongue daily
2 Lorazepam 2 Mg/ml Oral Concent Take 0.5mL BID
3 No Otc Meds. (OTC)
1/11/13 Pt has not started Lorazepam; will to discuss with provider
Allergy/Adverse Reaction:
No Known Drug Allergies
Social History:
Social history reviewed and unchanged on Jan 11, 2013 by, MA.
Patient has never smoked or used tobacco products.
He denies alcohol use.
He denies recreational drug use.
Patient is divorced.
Caffeine intake consists of He denies drinking caffeinated coffee., He denies drinking caffeinated soda., He denies drinking caffeinated tea. He denies exposure to 2nd hand smoke.
Family History:
Family history reviewed and unchanged on Jan 11, 2013 by, MA. Family history unremarkable.
Medical History:
Reviewed and unchanged on Jan 11, 2013: allergies, current medication list, medical history, immunizations, by, MA.
He has not been hospitalized or visited the ER in the last 12 months. Specialist(s) seen: Psychology-Psychiatry:xxx
Schizophrenia.
Surgeries- Procedures: No surgical history.
HPI:
Patient presents to xxx and office visit conducted with psychiatrist via Telehealth.
Patient did not endorse symptoms of persistently elevated mood, inflated self-esteem or grandiosity, increased interest in goal-directed activitiies, lack of sleep or need for sleep, distractibiltiy or disinhibited behavior, (e.g. excessive spending, sexual indiscretion) to suggest mania/hypomania.
PSYCHOSIS: Presents with features consistent with psychosis, including: delusions, no hallucinations, thought withdrawal or insertion.
The pt with catatonic schizophrenia. He continus to do well. Admits having some twitching of his arm last wk. Informed the dad about the risk of tardive diskinesia with antipsycotics. The pt is sleeping well, eating well. not catatonic anymore. He still have baseline delusion, but no obvious delusion or psychosis noted.
ROS:
Current medications reviewed. Past medical history, family history, and social history reviewed.
Mental Status Exam:
Appearance: Dressed casually. Well groomed. Good rapport and good eye contact. Behavior: No psychomotor agitation or retardation noted. Not observed to respond to hallucinations. Speech: Spontaneous, comprehensible, and normal in rate, rhythm, and volume. Mood: Patient describes mood as "okay". Affect: Affect is restricted, poor eye contact. Thought Process: Thought process observed to be at times not longical. Thought Content: Patient has delusions of. Patient denies any homicidal ideas. Patient denies any suicidal ideas. Perception: No hallucinations in any sensory modality. Insight: Intact. Patient understands illness, and seeks help appropriately. Patient is alert and oriented in time, place, and person.
Diagnosis:
295.2 Catatonic Schizophrenia
Prescription:
Refill Added:
(1) Zyprexa Zydis 20 Mg Tablet 2 time(s)
Care Plan:
Patient is not imminently suicidal, homicidal, floridly psychotic, or unable to care for self, and therefore does not require urgent in-patient care/intervention. Patient advised to go to the nearest emergency room or call 911 if suicidal or homicidal or experiencing a severe deterioration in his mental health. 24 Hour Mental Health Crisis Lines. Supportive counseling offered. Encouraged to continue with or seek individual counseling/therapy. Discussed treatment options including the option of no treatment and discussed risk versus benefits. Discussed side effects and adverse effects of all newly prescribed medications, and offered printed patient information material on newly prescribed medications. Advised to avoid use of machinery or driving until sure how medications affect/assess drowsiness. Patient also warned of the potential for suicidal ideation or an increase in SI occuring with SSRI and has been advised to adhere to the safety advise as listed below. Follow-up with primary care provider with any health care concerns. Advised to stay away from alcohol and illegal substances. Recommend patient be seen by a Behavioral Health provider (psychologist or Licensed Clinical Social Worker). Follow-up with Dr. X in 2 month(s).
The pt continus to do well, not catatonic anymore.
-- Continue Zyprexa 20mg daily
-- Continue atian 1mg bid prn
-- Need basic labs next visit.
This visit note has been electronically signed off by following providers.