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Posts: 85
Joined: Fri Jun 23, 2017 1:41 pm
Location: Multi-specialty Clinic

Thu Jul 06, 2017 10:58 am

Can anyone tell me if this is more than a detailed psychiatric examination? I have used 95 and 97 guidelines and can't seem to get a comprehensive examination. Our MAC provider is First Coast Service Options. :cry:

Vital signs: Pulse, RR, SPO2, and BP documented
Appearance: African American man, hospital pajamas, poor dental hygiene, he is calm, cooperative and pleasant
Speech: Unremarkable
Orientation: x 3
Memory: Unremarkable
Thought Process: logical
Thought Content: Unremarkable
Hallucination Type: None
Attention and Concentration: Good
Suicidal Ideation: No
Previous Suicide Attempts: No
Homicidal Ideation: No
Previous Homicide Attempts: No
Judgment: WNL
Affect: Good
Mood: Appropriate
Motor Activity: Normal gait
Posts: 85
Joined: Fri Jun 23, 2017 1:41 pm
Location: Multi-specialty Clinic

Fri Jul 14, 2017 8:05 am

Since I am not getting a response to this, would anyone know where there may be a psychiatric blog or forum? I post on this and E/M University and psych questions are not usually addressed. I know it is a "limited" area of expertise, but any information would be appreciated. Our facility has an adult inpatient and Mental health community clinic and inpatient hospital for kids. :shock: :o Any guidance would be appreciated.
Posts: 1
Joined: Fri Oct 20, 2017 12:31 pm

Fri Oct 20, 2017 12:59 pm

I just joined this group, therefore I am very late on responding to your psychiatric examination question.

CPT/Medicare/Joint Commission list the following for a psychiatric exam:

Description of thought processes
Description of associations
Description of abnormal or psychotic thoughts including:.
Mood and Affect
Judgment & Insight (The Joint Commission is requiring us to document "Intellectual Functioning" in this section now.)
Orientation to time, place and person
Attention span and concentration
Memory (JC requires us to document the "scale/means of measurement" that was used to determine the pt's memory
Fund of knowledge (JC requires us to document what the measurement that was used to determine the fund of knowledge)
Muscle Strength and tone or,
Examination of Gait and Station

All 14 exam elements are required to be Comprehensive, therefore your exam is Detailed.

I hope this helps!

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