Examination

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Examination

Postby Shoshana » Thu Jan 11, 2018 6:21 pm

i have a psychiatrist that wants full credit for a comprehensive examination when the patient is unable to do a mini-mental assessment. I thought credit was only given in the subjective areas, hx, ros, pfsh, when a patient was unable to supply information after all attempts (family members, chart, etc.) were exhausted. I do not remember reading anything about the objective examination being eligible for credit if the patient was unable to participate. Can someone advise me if I am missing something ;)
"In any moment or decision, the best thing you can do is the right thing." - T.Roosevelt
Shoshana, BA, CPC, CPMA, CPCO, RRT
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Re: Examination

Postby admin » Mon Jan 22, 2018 4:07 pm

Hello, I cannot find any Medicare, or specialty society, information saying that the patient unable to perform a mini mental assessment would result in supporting a comprehensive exam.

What type of service are they performing that would be impacted by this? Not all services that a psychiatrist performs require this element. If they are able to support the encounter without it, it is not overly concerning as long the documentation supports why it is unobtainable. If the encounter does require it, and it was not performed, then it is very likely it will not be supported to the same level.

Why are they unable to complete the mini mental assessment? If it was unobtainable due to the patients condition, then the psychiatrist should document why it was unable to be obtained. The patients behavior or refusal, may support minimal requirements.

Unfortunately there not many situations in which the absence of the mini mental assessment would be supported when it is absent.

Your question has been answered by Omega Renne, CPC, CPCO, CPMA, CEMC, CIMC
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Re: Examination

Postby Shoshana » Tue Jan 23, 2018 5:27 pm

This is a consultation in the Inpatient setting to decide if the patient needs to be admitted to Psych inpatient services after medically cleared.
"In any moment or decision, the best thing you can do is the right thing." - T.Roosevelt
Shoshana, BA, CPC, CPMA, CPCO, RRT
Shoshana
 
Posts: 52
Joined: Fri Jun 23, 2017 5:41 pm
Location: Hospital

Re: Examination

Postby admin » Mon Jan 29, 2018 1:26 pm

Hello,

In the IP setting, if psych is doing a consultation there should be at least one element of the psych examination. However, a mini mental assessment is not required for the IP consultation documentation requirements. It can be either a complete psychiatric examination based on 97 documentation guidelines, or a single element in 8 separate organ systems, based on 95 documentation guidelines.

If there is some reason why it is unobtainable, the documentation would have to very explicit in addressing why a. it cannot be obtained and b. why psych needed to evaluate a patient that cannot be evaluated for mental status.

Your question has been answered by Omega Renne, CPC, CPCO, CPMA, CEMC, CIMC
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