I agree with the previous poster who suggested a symptom or sign almost always exists to support the reason for the evaluation. This scenario is common in the elderly. A hospitalist or primary care sees a patient who may be non-compliant, generally eccentric or screens positive for symptoms of mental illness or incapacity. Automatically a request is made for mental health to evaluate to patient for either personal competence or to initiate mental health services. A percentage of these patients have no real underlying issues that constitute a mental illness diagnosis. This is problematic for the coder in that Axis I and II are devoid of a valid diagnosis.
Based on the LCD/NCD I reviewed, the V71.09 would be covered and appropriate for those patient's without symptoms (e.g., perhaps those who need competency evaluations). However, since most of these folks have specific symptoms that trigger the exam, utilizing one of those symptoms codes seems most appropriate (given that they represent the reason the examination was ordered/requested). Those symptom codes are, of course, mutually exclusive of the "Observation" V-codes, and thus should not be utilized together.
Also, review your own LCD or NCD (per the carrier you are submitting claims to). There are some rather vague V-codes that may be appropriate (e.g., mental or behavioral problems). Also, sequencing of your diagnoses codes may be the issue. Pay close attention and also speak with the carrier to see if you can establish any specific recommendations on diagnostic code sequencing.
Kevin B. Shields, RHIT, CPCO, CCS, CPC, COC, CCS-P, CPC-P, CPC-I