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Need code for Psychiatric consultation

  1. #1
    Default Need code for Psychiatric consultation
    Medical Coding Books
    Hi All,

    I am very new to the psychiatric coding, please help me to code below document.

    I have received document stating "Psychiatric consultation report"

    document look like normal E/M document,

    for History- cc, HPI, hx, ROS- has documented

    for Exam- mental status exam was done(General appearence, speech, mood/affect, memory, sensorium/orientation, hallucination, language, homicidal & sucidal ideation, calculation ability, thought process, HEENT, musculo/skeltal)

    lab studies had done.

    Kindly advice what CPT code should be used for above document, however timing also not given.

    Advance thanks to all,

    Banu, CPC

  2. #2
    Dover Seacoast New Hampshire
    If your provider is a psychiatrist and not a psychologist, then you can code an E&M visits, but you would need to meet the criteria for a consultation in order to bill such a code. CPT has changes in 2010, but basically, request, opinion and report still apply. Based on what little information you've given, I can't suggest a level of service from an auditing perspective. Is there a detailed history documented? Problem focused exam? Without seeing the entire note, I can't recommend any code, sorry.

    If your provider is a psychologist, you'll have to report a diagnostic interview, 90801
    Last edited by Pam Brooks; 02-04-2010 at 04:42 AM. Reason: mis-spelling.

  3. #3
    Have you considered using 90801? Without seeing the documentation I can't say for sure. In my area of the country, the code can be used by Psychiatrist, Psychologist and LCSW's.

  4. Smile ED coder
    I also use Sara...

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