Mental Health

[Debi]

We recently started coding for mental health at our facility, however this is such a gray area for us. I am wondering if anyone could shed some light on mental health billing. The E&M part of just a follow up appt. The criteria that is needed in these notes. Or if someone has a current reference that they would not mind sharing. Any information would be helpful.

Thank you.

 

[Regina]

What type of providers are you billing for? Is this facility an inpatient or outpatient facility?

 

[Debi]

This is for outpatient clinic, we have a Psychitrist and a Nurse Practioner with speciality in Psychiatric.

 

[Regina]

What specific questions do you have? Mental health billing is the easiest, to me, however, there is alot you must do. It would be better to answer specific questions for you.

 

[Debi]

I guess we are having problems with the documentation that we are seeing. We are just struggling with making sure the appropriate information in is the chart in order to bill . I could give you an example of what we see if that would help.

 

[Regina]

It would help. Do you use papercharts or EMR?

 

[Debi]

We use EMR

Example:
Present for Interview: Patient
Allergies: Flexaril
Current Psychiatric RX: methylphenidate 20 mg
Subjective/Chief Complaint- this paitne presents for a follow up. **** feels like the methyplphnidate is working well for her. She has been able to complete her workday with a problem and still has been sleeping well at night. ***hopes her work load will decrease soon which would be helpful to decrease her stress level. Will see the patient again in 4 weeks or sooner if needed.

Assessment
Axis I: 314.00, 300.04, 300.02

Risk Assessment: Low
Therapeutic Interventions: Medication management
treatment Goals: Reduce symptoms

Plan:No changes to current medication regimen. Provide support to patient to provdie psychotherapy concerning diagnosis, treatment, medication management.

 

[Regina]

Make sure you add your start and stop times to each visit note, this is now required. These times are equally beneficial for billing. Does your EMR give you the option to input your CPT codes? If so, use that. Is your EMR for medical or is it a program strictly for Mental Health?