I would check with your Medicare carrier - many have a specific publication for Mental Health. Use that as a guide. Also check for a Local Policy - here is Michigan we have several concerning Mental Health.
From those see what codes you are looking at and the requirements ie ability to partitipate in treatment, medication side effects and overall effectivenets, mental status exam (and definition of what is included in that).
From that make yourself a template just as you would in the old days for an E&M (pre computers)
For me the tricky part is usually the mental status exam - the 1997 Guidlines mention a mental status exam to include the followin items listed. I usually use the items there and in the rest of the physical exam for mental health. it is a good source. Or if the practice has one they are using that at least incorporates the items listed from 1997 as a part of the mental status exam.
Lastly, learn what the AXIS is and what AXIS 1-4 mean if they use them in their documentation. Does that help?
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