Psychiatry Coding & Reimbursement Alert

Question: Our psychiatrist performed an E/M service and noted suicidal ideation during the service. Can suicidal ideation increase the level of the E/M code that we are using to report the visit?

New York Subscriber

Answer: To determine the level of E/M code, you should factor in all of the components that your clinician has covered. That means you should consider all the components, such as the level of history, level of physical examination, and complexity of medical decision making, to determine what E/M code you will choose to report.

Even though suicidal ideation increases the risk of patient mortality, it cannot be considered as the sole criterion for achieving a high level of complexity of medical decision making. For MDM, you should include all the other complexity criteria, such as the number of diagnoses/ management options considered; amount and/or complexity of data reviewed/ ordered; along with the risk of complications and patient mortality or morbidity, should be considered to determine the complexity level.

So, although you have a higher risk of mortality in a patient with suicidal ideation, this, by itself, cannot increase the level of E/M code that you will report for the visit. All the other E/M criteria should be considered, and the fact that the patient has a high risk of committing suicide should be factored into those criteria, especially the medical decision making,to determine the level of E/M code you should report for the visit.