Brenda1973
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Please help me decide if I should be adding R45.851 to this claim.
1.This is the documentation in the HPI."She noticed an increase in wellbutrin helped with her mood and decreased how often she was having SI. She had more passive SI the past two weeks. She always has a plan of pills for suicide, but she says she didn't come close to attempting it. She didn't further her SI and does not meet 302 criteria. She recently let her church know about her depression"
2.Provider documents " Thought content: denies SI/HI, no evidence of mania or psychosis" in the mental status exam.
3.Provider does not document any wording in the assessment and plan about the suicidal ideation.
As a coder I am not sure when it should be added to the claim, as it is worded in the HPI but provider seems to ignore it in the rest of the note. Please advise me. Thanks!
1.This is the documentation in the HPI."She noticed an increase in wellbutrin helped with her mood and decreased how often she was having SI. She had more passive SI the past two weeks. She always has a plan of pills for suicide, but she says she didn't come close to attempting it. She didn't further her SI and does not meet 302 criteria. She recently let her church know about her depression"
2.Provider documents " Thought content: denies SI/HI, no evidence of mania or psychosis" in the mental status exam.
3.Provider does not document any wording in the assessment and plan about the suicidal ideation.
As a coder I am not sure when it should be added to the claim, as it is worded in the HPI but provider seems to ignore it in the rest of the note. Please advise me. Thanks!