Wiki Coding Scenario

[tgenius1]

Help Coding Scenario - Current Audit

Mental Health
CC: I am not feeling good
HPI: Return visit by this 45 year old male. Patient with Major Depression Disorder and Alcohol
Abuse. The provider performed an expanded problem focused history, an expanded problem
focused exam, and a low medical decision making.
Assessment
Depression
Alcohol Abuse
Insomnia
Psychotherapy of 45 minutes, discussed daily life, his sense of injustice being chronically ill, anger
management, how to handle the stress. Practiced deep breathing exercises this visit which patient
says he has not done before. Discussed his behavior and how he can change in a fit of anger.

I coded 99213-25, 90834, F32.3, F10.1. Did i Code this case correctly?

 

[ckeeney]

I would code 99213, 90836 (add-on code for 45 min. psychotherapy in conjunction with E/M service). Why F32.3? There is no mention of severity or psychotic features. F32.9, MDD, single episode, unspecified/depression NOS, would, in my opinion, be more appropriate based on the documentation provided. F10.1 also.

 

[tgenius1]

Perfect! Thanks for breaking this one down for me. I have never coded mental health before not my forte!