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Wiki Psychiatric Eval, history not complete
- Thread starter Nstmarie
- Start date
Pathos
True Blue
The CPT 2018 book explains:
"Psychiatric diagnostic evaluation with medical services is an integrated biopsychosocial and medical assessment, including history, mental status, other physical examination elements as indicated, and recommendations. The evaluation may include communication with family or other sources, prescription of medications, and review and ordering of laboratory or other diagnostic studies."
CGS (KY/OH MAC) also explains:
Psychiatric Diagnostic Interview Examination
(CPT codes 90791-90792) Require the following:
• Elicitation of a complete medical and psychiatric history (including past, family, social)
I am not sure what you are referring to when stating "Legal History", but social history should be one of the components documented when billing 90791. If left blank, then this code would not be appropriate to bill.
"Psychiatric diagnostic evaluation with medical services is an integrated biopsychosocial and medical assessment, including history, mental status, other physical examination elements as indicated, and recommendations. The evaluation may include communication with family or other sources, prescription of medications, and review and ordering of laboratory or other diagnostic studies."
CGS (KY/OH MAC) also explains:
Psychiatric Diagnostic Interview Examination
(CPT codes 90791-90792) Require the following:
• Elicitation of a complete medical and psychiatric history (including past, family, social)
I am not sure what you are referring to when stating "Legal History", but social history should be one of the components documented when billing 90791. If left blank, then this code would not be appropriate to bill.
NiteshlalKoyalkar
Networker
HI,
In certain circumstances one or more other informants (family members, guardians, or significant others) may be seen in lieu of the patient. Codes 90791, 90792 may be reported more than once for the patient when separate diagnostic evaluations are conducted with the patient and other informants. Report services as being provided to the patient and not the informant or other party in such circumstances.
in certain cases if history is not able to obtain from patient, then it can be obtained through the patient family .
if history is not collected from patient or family then 90791, 90792 is not qualified to code.
In certain circumstances one or more other informants (family members, guardians, or significant others) may be seen in lieu of the patient. Codes 90791, 90792 may be reported more than once for the patient when separate diagnostic evaluations are conducted with the patient and other informants. Report services as being provided to the patient and not the informant or other party in such circumstances.
in certain cases if history is not able to obtain from patient, then it can be obtained through the patient family .
if history is not collected from patient or family then 90791, 90792 is not qualified to code.