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Thread: Psychiatric examination 1997 guidelines

  1. #1

    Default Psychiatric examination 1997 guidelines

    AAPC: Back to School
    Can someone clarify the requirement of the shaded and unshaded statement mentioned under comprehensive examination for psychiatry? I just started coding psychiatry on a regular basis and I am confused with the coding tool I am using vs the information in the 1997 guidelines under detailed and comprehensive examination. The following information is taken from the 97 single organ system exam:

    Detailed Examination--examinations other than the eye and psychiatric
    examinations should include performance and documentation of at least
    twelve elements identified by a bullet (•), whether in box with a shaded or
    unshaded border.
    Eye and psychiatric examinations should include the
    performance and documentation of at least nine elements
    identified by a bullet (•), whether in a box with a shaded or
    unshaded border.
    • Comprehensive Examination--should include performance of all elements
    identified by a bullet (•), whether in a shaded or unshaded box.
    Documentation of every element in each box with a shaded border and at least one element in each box with an unshaded border.

    As I understand it, in order to have a comprehensive exam, the physician should document all elements in a shaded box and at least one element in each unshaded box. My physicians has been just documenting a mental status examnination, which are in the shaded boxes. ( The ones I do are all inpatient consults for psychiatrist, if that makes a difference, I know sometimes there are different criteria for psychiatrist vs psychologist)

    The 95 guidelines states you need 8 or more organ systems for comprehensive and 2 to 7 for detail. Is the mental staus exam sufficient or would they need to document the other organs to equal up to 8 or more as well?

    What will be the best way to determine which guideline I should use? the physicians only document a mental status exam, they do not document the other body areas/organ systems

    If you can, please provide feed back for both 97 and 95 that pertains to the above.

    Thanks in advance!
    Last edited by Trendale; 04-07-2010 at 02:40 PM.

  2. #2

    Default Re: Psychiatric Examination

    You might get a higher level E&M with 1997 guidelines if they are only documenting mental status exams. With the 1995 guidelines, they would need to have 1 other area besides Psychiatric for detailed, but the 1997 guidelines only mention the required number of bullets (9) regardless of one or more systems.

    For 1997 guidelines for Comprehensive Level, they would need to examine the constitutional (measurement of vital signs and general appearance), either assess muscle strength and tone or examine gait and station, and do all the bullets in the Psychiatric exam.

    Hope this helps you.

    Sue Stack

  3. #3

    Default reply to Suestack 97 pysch exam

    Thanks for that information. I have another concern regarding comprehensive. On page 40 of the guidelines for psych, where it says content and documentation requirements,there is a statement next to comprehensive, that states, perform ALL elements identified by a bullet;document every element in each box with a shaded border and at least one element in EACH box with an unshaded border, What does this statement pertains to if we are looking at the constitutional, musculoskeletal and psych for comprehensive? That is the part that was confusing me on the 97 guideline.

    Also, regarding the 95 guideline for detailed, you said you need one other area. I am confused on that part. As I understand it, maybe I am understanding it wrong, but I thought you need 2-7 body/organ systems as stated in the guideline, and document one or more in detail. when it states document one or more in detail, I was thinking that it meant, the physician has to document in detail the body or organ system he listed out of the 2-7 body organs, or areas; for example; extremity- edema, swelling etc. Or maybe I thingk this is what you are saying, the physician has to document another area or system in detail in addition to the 2-7 that he list. So in other words he would have to list 8 with one in a detailed description?

    Thanks so much for your help, I am only asking more questions, so that I can understand it better.

  4. #4


    Using 1997 guidelines for a psych visit, you would need to have every bullet in the psych section, every bullet in the Const, and atleast one in the MS section. No other body systems need to be done.

  5. #5
    Join Date
    Apr 2007
    Milwaukee WI

    Default 1997 vs 1995

    1997 guidelines Psych specialty exam
    DETAILED exam - you must document at least 9 bullets (there are a total of 15 bullets listed)
    COMPREHENSIVE EXAM - you must document every bullet in a shaded section (2 in constitutional, 11 in psych) PLUS at least one in the unshaded box (musculoskeletal)

    1995 Guidelines
    DETAILED exam - you need to document an extensive exam of the affected body area or organ system (psych in the case of a psych patient), plus other related/symptomatic organ systems (any ONE will do - pupils? muscle tone? gait? general appearance?)
    COMPREHENSIVE exam - you must document examination of 8 organ systems

    If ALL your psychiatrists are documenting are the 6 bullets in the complete mental status exam then you have an Expanded Problem Focused exam per 1997 guidelines. You have only a problem focused exam per 1995 guidelines.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC
    Last edited by FTessaBartels; 04-14-2010 at 03:24 PM.

  6. #6

    Default Reply regarding psych 97 and 95 exam guidelines

    Sorry, I am just getting back to this, but thanks for everyone's feedback, it helped a lot!

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