Psychiatry Coding & Reimbursement Alert

Question: A patient comes in with a chief complaint of “increasing forgetfulness.” How could I apply the mini mental status exam (MMSE) into the history component’s history of present illness (HPI)? Should I count it as context? Or could it be part of the E/M level’s medical decision making (MDM)?

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Answer: You note that “increasing forgetfulness” is the patient’s chief complaint. The chief complaint is distinct from the HPI. Documentation of the development of the patient’s increasing forgetfulness, however, could be counted under HPI. Here’s how:

From a CPT^® perspective, HPI is a chronological description of the development of the patient’s present illness from the first sign and/or symptom to the present. This may include a description of location, quality, severity, timing, context, modifying factors, and associated signs and symptoms significantly related to the presenting problem(s). Thus, under HPI, a statement of the condition’s quality could be relevant. For example, a statement that the forgetfulness is increasing or chronic described its quality and lends to the HPI.

Context, on the other hand, is a description of where the patient is or what he is doing when the signs or symptoms begin. A context note could indicate the forgetfulness has increased since, for instance, the patient fell from the porch.

If the note was part of the questions your clinician asked the patient, he could alternatively count forgetfulness under psychiatric review of systems (ROS). Be careful to count the statement only once under HPI or ROS.

MMSE performance and documentation may contribute to the encounter’s exam and MDM level. The 1997 Documentation Guidelines for Evaluation and Management Services’ General Multi-System Examination references, under the Psychiatric organ system, brief assessment of mental status including:

• orientation to time, place, and person
• recent and remote memory
• mood and affect (such as depression, anxiety, and agitation).

When selecting the MDM level, your clinician could include how the MMSE’s results impacted his assessment of the patient’s condition and his recommendations for additional data (for instance, tests ordered) or management options.