Wiki Psychiatric exam elements question

[donaldjr1969]

I have been doing some practice coding with client chart notes to get a leg up on coding psych exams using the 2013 CPT guidelines. Being that I am a newly certified coder (certified 7-2012), I have a question on how much to include for exam elements. Specifically I am referring to the Mood and Effect element of a psych exam.

Here is my question. If the doctor, counselor, etc indicates multiple moods in the course of the examination, do I code the exam as if each separate mood is a separate data point? Or is it only one data point regardless of how many moods are indicated in the chart note? As an example, say the examiner notes moods of anxiety as well as depression. Do those two moods count as one or two exam elements for coding purposes?

I thank you in advance.

 

[cac_vo22]

billing & auditing

Go to CMS.gov to pull the E/M 97 guideline & you will see the examination requirements (by CMS) for psychiatry.
Mood and affect is considered 1 bullet of the examination. Depression, anxiety...all fall under this bullet. You can't count for how many moods documented bcz the examination has listed only 1 bullet for mood.
Hope this would help.