Wiki help in psychiatric evaluation

debipbarik

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In psychiatric evaluation if physician documented adequate HPI as Exapnded problem focused,chief complain, 1 pertinent PFSH but did not documented any ROS other than Psychiatric, then what will be the level of HISTORY?
If in above case psychiatric exam is problem focused(1-5 bullets) and MDM is of moderate complexity, what level of office visit we will code for a Established patient?

I will be very thankful if anybody helps in above case.:):)
 
So, if you have one ROS (Psych) pertinent to the problem along with the other info you mentioned, your level of history would be exp prob focused. For an established pt, an Exp Prob Foc hx/prob foc exam/mod mdm would code out to a 99213 (2/3 key components met)
 
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