torresreb
Networker
During an encounter a patient was referred to be evaluated for depression.
example:
DOS xx/xx/xx - patient exceeded 9 points during a PHQ9 screening. Due to depression the patient was referred to social workers for an assessment and/or treatment plan if applicable.
DOS xx/xx/xx (a week later) - the patient was evaluated and found to have dysthymia.
During the coding process the documentation was not sufficient enough to support the diagnosis (missing assessment plan, does not reference how or why the patient was referred etc). How should it be coded? Both in ICD9 and ICD10 worlds?
My thought is to assign 311 and/or F32.9 - (depression NOS/Major Depression) (ICD9 & ICD10) as that was the reason the patient was referred for the second date of service. I would also assign this code if after the end of the evaluation the patient decides to not continue with services.
Does anyone have an opinion? Please, thank you!
example:
DOS xx/xx/xx - patient exceeded 9 points during a PHQ9 screening. Due to depression the patient was referred to social workers for an assessment and/or treatment plan if applicable.
DOS xx/xx/xx (a week later) - the patient was evaluated and found to have dysthymia.
During the coding process the documentation was not sufficient enough to support the diagnosis (missing assessment plan, does not reference how or why the patient was referred etc). How should it be coded? Both in ICD9 and ICD10 worlds?
My thought is to assign 311 and/or F32.9 - (depression NOS/Major Depression) (ICD9 & ICD10) as that was the reason the patient was referred for the second date of service. I would also assign this code if after the end of the evaluation the patient decides to not continue with services.
Does anyone have an opinion? Please, thank you!