Trendale
Guest
Hello,
Can someone clarify the requirement of the shaded and unshaded statement mentioned under comprehensive examination for psychiatry? I just started coding psychiatry on a regular basis and I am confused with the coding tool I am using vs the information in the 1997 guidelines under detailed and comprehensive examination. The following information is taken from the 97 single organ system exam:
Detailed Examination--examinations other than the eye and psychiatric
examinations should include performance and documentation of at least
twelve elements identified by a bullet (•), whether in box with a shaded or
unshaded border.
Eye and psychiatric examinations should include the
performance and documentation of at least nine elements
identified by a bullet (•), whether in a box with a shaded or
unshaded border.
• Comprehensive Examination--should include performance of all elements
identified by a bullet (•), whether in a shaded or unshaded box.
Documentation of every element in each box with a shaded border and at least one element in each box with an unshaded border.
As I understand it, in order to have a comprehensive exam, the physician should document all elements in a shaded box and at least one element in each unshaded box. My physicians has been just documenting a mental status examnination, which are in the shaded boxes. ( The ones I do are all inpatient consults for psychiatrist, if that makes a difference, I know sometimes there are different criteria for psychiatrist vs psychologist)
The 95 guidelines states you need 8 or more organ systems for comprehensive and 2 to 7 for detail. Is the mental staus exam sufficient or would they need to document the other organs to equal up to 8 or more as well?
What will be the best way to determine which guideline I should use? the physicians only document a mental status exam, they do not document the other body areas/organ systems
If you can, please provide feed back for both 97 and 95 that pertains to the above.
Thanks in advance!
Can someone clarify the requirement of the shaded and unshaded statement mentioned under comprehensive examination for psychiatry? I just started coding psychiatry on a regular basis and I am confused with the coding tool I am using vs the information in the 1997 guidelines under detailed and comprehensive examination. The following information is taken from the 97 single organ system exam:
Detailed Examination--examinations other than the eye and psychiatric
examinations should include performance and documentation of at least
twelve elements identified by a bullet (•), whether in box with a shaded or
unshaded border.
Eye and psychiatric examinations should include the
performance and documentation of at least nine elements
identified by a bullet (•), whether in a box with a shaded or
unshaded border.
• Comprehensive Examination--should include performance of all elements
identified by a bullet (•), whether in a shaded or unshaded box.
Documentation of every element in each box with a shaded border and at least one element in each box with an unshaded border.
As I understand it, in order to have a comprehensive exam, the physician should document all elements in a shaded box and at least one element in each unshaded box. My physicians has been just documenting a mental status examnination, which are in the shaded boxes. ( The ones I do are all inpatient consults for psychiatrist, if that makes a difference, I know sometimes there are different criteria for psychiatrist vs psychologist)
The 95 guidelines states you need 8 or more organ systems for comprehensive and 2 to 7 for detail. Is the mental staus exam sufficient or would they need to document the other organs to equal up to 8 or more as well?
What will be the best way to determine which guideline I should use? the physicians only document a mental status exam, they do not document the other body areas/organ systems
If you can, please provide feed back for both 97 and 95 that pertains to the above.
Thanks in advance!
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