Wiki New to psych coding, need help auditing

[buppkl]

I have never coded for psychiatry before and I hope I am explaining my question clearly. When using the specialty psych exam audit sheet to code the E/M visits, in the exam portion under the psych section, must all 6 bullets in the "Complete Mental Status Exam" be identified in order to count the CMS exam (worth 1 bullet)? I easily can check the 5 bullets above the CMS exam, but it seems I am always missing one bullet on the CMS exam and then cannot credit the doc for any of the CMS portion. My Medicare carrier (Novitas) does not state on the audit sheet or the exam sheet that all 6 indicators must be met to give credit. Anyone have any thoughts?

 

[ckeeney]

We use the 1997 Guidelines for our psychiatric E/M services. How many of the items were evaluated determines the exam level.
ELEMENTS OF EXAMINATION:
PF = 1 body area or organ system, EPF = 6 elements D = 9 or more elements C = ALL ELEMENTS (all bullets in shaded, at least 1 in unshaded)

Constitutional(shaded) – any 3 of the following vital signs
BP___Supine BP____Pulse Rate & Reg___Respiration___Temp___Height___Weight___
• General appearance of patient (development, deformities, grooming)______
Musculoskeletal (unshaded):
• Muscle strength and tone (flaccid, cog wheel, spastic) _____
• Gait and station____
Psychiatric (shaded)
• Speech (including rate, volume, articulation, coherence and spontaniety with notation of abnormalities (perseveration, paucity of language)____

• Thought processes: rate of thoughts, content of thoughts (logical or illogical); abstract reasoning; computation____

• Associations (loose, tangential, circumstantial, intact)_____

• Abnormal or psychotic thoughts: hallucinations; delusions; violence; homicidal or suicidal ideation; obsessions______________

• Judgment: (concerning everyday activities and social situations) and insight (concerning psychiatric condition)______

• Orientation to time and place______
• Memory_______
• Attention Span and Concentration_____
• Language (naming objects, repeating phrases)_____
• Fund of knowledge (awareness of current events, past history, vocab)____
• Mood and Affect (depression, anxiety, agitation, hypomania, lability)______