Wiki Psychology

[hartford1]

Good morning, I am an auditor/educator and I started a new job recently. One of my assigned specialities is Psychology and I have not had a ton of experience in this, I’m looking to anyone who has experience in this for some advice, I’m looking for good resources on the web that will help me in this area. I actually have a meeting set up for Friday with a provider who is looking for some coding guidance but I need to wrap me head around it all first. Any good resources I would love.
Thank you!

 

[TThivierge]

Hi Hartford
Ensure provider document the pt problems and signs, then add assessment/dx, plus suggest a plan of care. Document if new vs est. patient. If new pt ensure as if chronic problem or on meds treated somewhere else. Ask on record current or past medical problems listed, and family and past social history. On history if past illness put a chorological date on it, helps the medical coder. Other tidbits in documenting...
1.Do not write see notes from another treatment date, or no cloning either
2.Do not write as dx code just substance abuse .define which one (alcohol, pills, cocaine, cannabis),
3.Ensure sign it and list professional initials,
4.If insurance company wants treatment plan required by provider complete and use same dx when pt comes for treatment
5. If a follow up return visit please tell concerning what return for=illness
6.If pt is a smoker can add minutes talk to pt in record, see CPT 99407. Dx F17 block This is additional service so can use the modifier 25 on CPT 90832-90838 when it applies.
7. Also minutes need to be noted in current documentation of any beh health CPT 90832-90839 , smoking cessations, telehealth of phone or video 98968 CPT series, or add modifier 95 to 90832 CPT series and note in if pt approved of phone or video and verify pt demographics info on top of treatment for the day.
8. Attention-deficit without hyperactivity (adolescent) (adult) (child) F98.8. However when I look in the tabular list F98.8 states P (pediatric) code. Payers deny this code due to age when used on a claim for an adult. Better to use dx R41.80 or F90.8, Other specified Attention-Deficit/Hyperactivity Disorder or F90.9, Unspecified Attention-Deficit/Hyperactivity Disorder.
9.Homelessness dx Z91 should be last dx and tell why pt. homeless reasons ill, depressed, drug addiction, stress ,unstable, no funds add definitive dx first
10.If pt in remission due to drug use or problem document it
11. Be detailed in defining stages of Dementia block dx F03, Depression F32, and add dx Z codes on end of claim related to pt s problems if necessary dx Z63, Z71
12. Can add screenings in day s treatment if appropriate add CPT 96127 PHQ9 for screening emotional problems and 96110 PHQ9 for child /adolescent development screenings
Well I hope this data helps you
Lady T

 

[TThivierge]

Hi Hartford
Here is outline of documenting for Psychiatric E/M HPI:

Location: Regarding mental status, location could correspond to domain (e.g., mood, thought process, perception, etc.)

Quality: Descriptive language (e.g., forgetful, depressed, disorganized, hallucinating)

Severity: Language that relates to how bad the problem is (e.g., “8 out of 10,” controlled, uncontrolled)

Timing: Language that relates to when symptoms are experienced, such as in certain situations or time of day

Duration: Onset of symptoms and how long symptoms last

Context: Psychosocial factors related to the problem

Modifying factors: What brings on or relieves the problem?

Associated signs and symptoms: What else is happening? (e.g., loss of functions/drives, such as appetite, weight, libido, etc.)

Have a good day and hope helped you a little bit.
Lady T