Hello all,
I need some insight on how to code for Psychiatry? When do I use the psych codes vs the E&M codes? Examples below
Psychiatric:
50-year-old single Caucasian female employed residing with family friends was seen
today. Patient is alert oriented x3 cooperative good eye
contact mood described better than before affect reactive normal speech spontaneous flow volume relevant
coherent patient denied any feelings of hopelessness helplessness denied suicidal homicidal ideations or plans
denied auditory visual hallucinations no evidence of acute psychosis paranoia delusion thought disorder
agitation noticed insight and judgment is fair recall 2 or 3 attention concentration is OK memory recent remote
is intact abstract thinking cognition intact denied use of any illicit drugs or alcohol patient claims addition of
Wellbutrin is helping her depression she does have crying spells but they are not bad patient miss her 2 cats
This supportive therapy coping skills relaxation techniques addressed with the patient patient was told that
living situation is more important than taking care of cats, cats are in good hands they are getting their food and
shelter and being taken care of and she can visit them patient agreed.
Diagnoses: Major depressive disorder, recurrent, moderate F33.1 Anxiety disorder, unspecified F41.9
Psychiatric:
40-year-old divorced Caucasian female employed history of bipolar depression anxiety
disorder was seen today. Patient is well-groomed cooperative good
hygiene good eye contact mood described good affect pleasant bright mood congruent speech spontaneous
relevant coherent logical denied any feelings of hopelessness helplessness denied suicidal homicidal ideations or
plans denied auditory visual hallucinations no evidence of acute psychosis paranoia delusion thought disorder
noticed insight and judgment is fair recall 3 of 3 attention concentration is OK memory recent remote is intact
abstract thinking cognition is intact denied use of any illicit drugs or alcohol denies any side effects from
medication patient claims addition of Latuda stabilize her mood is much better no side effects reported. Patient
also mentioned the ex husband passed drug test now patient's children are visiting dad , 16-years-old son and
14 yr old daughter. they go and visit the father because before that he was using drugs and patient was
extremely uncomfortable with it now patient claims the ex-husband passed the drug test and he is allowed to
take children and spend time with him coping skills compliance with the treatment daily life's stressors job
related stress addressed will follow up in 3 months patient blood work is due in may, 2023.
Diagnoses: Bipolar disorder, current episode depressed, moderate F31.32 Anxiety disorder, unspecified F41.9
Thank you so much!
I need some insight on how to code for Psychiatry? When do I use the psych codes vs the E&M codes? Examples below
Psychiatric:
50-year-old single Caucasian female employed residing with family friends was seen
today. Patient is alert oriented x3 cooperative good eye
contact mood described better than before affect reactive normal speech spontaneous flow volume relevant
coherent patient denied any feelings of hopelessness helplessness denied suicidal homicidal ideations or plans
denied auditory visual hallucinations no evidence of acute psychosis paranoia delusion thought disorder
agitation noticed insight and judgment is fair recall 2 or 3 attention concentration is OK memory recent remote
is intact abstract thinking cognition intact denied use of any illicit drugs or alcohol patient claims addition of
Wellbutrin is helping her depression she does have crying spells but they are not bad patient miss her 2 cats
This supportive therapy coping skills relaxation techniques addressed with the patient patient was told that
living situation is more important than taking care of cats, cats are in good hands they are getting their food and
shelter and being taken care of and she can visit them patient agreed.
Diagnoses: Major depressive disorder, recurrent, moderate F33.1 Anxiety disorder, unspecified F41.9
Psychiatric:
40-year-old divorced Caucasian female employed history of bipolar depression anxiety
disorder was seen today. Patient is well-groomed cooperative good
hygiene good eye contact mood described good affect pleasant bright mood congruent speech spontaneous
relevant coherent logical denied any feelings of hopelessness helplessness denied suicidal homicidal ideations or
plans denied auditory visual hallucinations no evidence of acute psychosis paranoia delusion thought disorder
noticed insight and judgment is fair recall 3 of 3 attention concentration is OK memory recent remote is intact
abstract thinking cognition is intact denied use of any illicit drugs or alcohol denies any side effects from
medication patient claims addition of Latuda stabilize her mood is much better no side effects reported. Patient
also mentioned the ex husband passed drug test now patient's children are visiting dad , 16-years-old son and
14 yr old daughter. they go and visit the father because before that he was using drugs and patient was
extremely uncomfortable with it now patient claims the ex-husband passed the drug test and he is allowed to
take children and spend time with him coping skills compliance with the treatment daily life's stressors job
related stress addressed will follow up in 3 months patient blood work is due in may, 2023.
Diagnoses: Bipolar disorder, current episode depressed, moderate F31.32 Anxiety disorder, unspecified F41.9
Thank you so much!
How did you determine moderate complexity was met? I don't see moderate MDM documented. Is there a different way you determine the complexity for psych? I see 2 stable chronic conditions, however, in the first chart note, there is no data to be ordered or reviewed, he mentions the patient doing well on Wellbutrin but doesn't mention the dosage, refills, etc., In the second note, he mentions medication, again no details, and indicates patient is due for BW but doesn't specify what, if anything, was ordered. Can these cases justify a 99214 per the documentation? Or is the diagnosis of the depression being moderate enough to support moderate complexity? I'm so sorry, I'm just trying so hard to understand and I am so appreciative for your help and patience!