Wiki Medication Education

[KimHolla]

I am coding in an inpatient psychiatric hospital and a doctor met with the pt. to discuss medication, necessary work-up prior to using medication, side effects, necessary labs, etc. Informing the pt of a specific medication in general. What ICD9 and CPT code do I use?

 

[Elaine09]

I am coding in an inpatient psychiatric hospital and a doctor met with the pt. to discuss medication, necessary work-up prior to using medication, side effects, necessary labs, etc. Informing the pt of a specific medication in general. What ICD9 and CPT code do I use?

You would use the ICD-9 diagnosis for the reason for the visit or reason for medication. for your CPT Code if dr did an e & m code that the records support the level you need to bill (look at the E & M in the inpatient hospital.) We can't not give you the exact codes without seeing the records. You doctor may be able to help you and point you in the correct direction.

 

[KimHolla]

Thank you but the medication is for the pt.'s mental illness and is prescribed by the psychiatrist. The medical doctor was having this discussion with the pt. and I was told that the medical doctors can not diagnosis mental illness (Schizophrenia). An E/M code will not work becase there was no history, exam or medical decision making. I was trying to capture for the doctors time but there wasn't an amount of time noted.