• If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten the password it can be reset on our sign in section by entering your registered Email Address or Username here. To start viewing messages, select the forum that you want to visit from the selection below..

Psychiatric exam elements question

D

donaldjr1969

Contributor
Messages
17
Location
Cuyahoga Falls, OH
I have been doing some practice coding with client chart notes to get a leg up on coding psych exams using the 2013 CPT guidelines. Being that I am a newly certified coder (certified 7-2012), I have a question on how much to include for exam elements. Specifically I am referring to the Mood and Effect element of a psych exam.

Here is my question. If the doctor, counselor, etc indicates multiple moods in the course of the examination, do I code the exam as if each separate mood is a separate data point? Or is it only one data point regardless of how many moods are indicated in the chart note? As an example, say the examiner notes moods of anxiety as well as depression. Do those two moods count as one or two exam elements for coding purposes?

I thank you in advance.
 
billing & auditing

Go to CMS.gov to pull the E/M 97 guideline & you will see the examination requirements (by CMS) for psychiatry.
Mood and affect is considered 1 bullet of the examination. Depression, anxiety...all fall under this bullet. You can't count for how many moods documented bcz the examination has listed only 1 bullet for mood.
Hope this would help.
 
You must log in or register to reply here.
Top