Wiki Psych Clinic- Number and Complexity of Problems Addressed

[amwittler]

I am new to coding for psych providers and I was wondering if I could get some guidance on determining the number and complexity of problems addressed. What happens when a patient has anxiety and depression that is managed by meds? Would that be a 99213 (low presenting problem) or 99214 (moderate presenting problem)? I ask that because not every patient with anxiety has depression so would that be considered two separate problems? Also, how do you know if a mental illness would be considered acute or chronic? What should I be looking for when it says says Acute illness with systemic symptoms?

Any basic information on leveling E/Ms for a psych clinic would be helpful. Thank you!

 

[jkyles]

Hi there, this is the sort of information the treating psychiatrist has to include in the note for each visit because otherwise you can't tell whether the doctor addressed the patient's depression, anxiety or both conditions. Similarly, the clinician must determine and indicate whether the problem they addressed at that visit is acute or chronic.

CPT Assistant has said that certain psychiatric can meet the definition of acute illness with systemic symptoms. Your best bet is to show the doctors the definitions for Acute or chronic illness or injury that poses a threat to life or bodily function and Acute illness with systemic symptoms in the CPT manual.