Patient 1: 45-Year-Old Male with MDD and Acute Crisis

1. Reimbursement Billing Code and Justification:

• Billing Code: 90792 (Psychiatric diagnostic evaluation with medical services) with a modifier to reflect the crisis nature of the visit, and potentially a 90839 or 90840 (Crisis psychotherapy) if that portion of the visit also took place.
• Justification:
  • The patient presented in acute crisis, with active suicidal ideation and a plan. The immediate need was a thorough psychiatric evaluation to assess his risk and determine the appropriate level of care.
  • Because medical services were rendered, by way of the mental status exam, and the evaluation of the risks present, the 90792 is highly appropriate.
  • Because the man is in a state of crisis, a code that represents that crisis is also very important.
  • The level of distress and immediate risk necessitates a code that reflects the complexity and urgency of the situation.

2. Pertinent Information Required for Documentation:

• DSM-5-TR Diagnoses:
  • Major Depressive Disorder, Severe, with Suicidal Ideation: Requires documentation of the patient’s depressed mood, anhedonia, sleep disturbances, impaired concentration, suicidal ideation with a plan, and the duration and severity of symptoms.
  • Alcohol Use Disorder: Requires documentation of the amount and frequency of alcohol use, and the negative consequences associated with the drinking.
  • Adjustment Disorder with Depressed Mood could also be added, dependant on further patient questioning.
• ICD-10 Coding:
  • F32.2 (Major depressive disorder, single episode, severe without psychotic features) with appropriate “suicidal ideation” additional code.
  • F10.10 (Alcohol abuse, uncomplicated). ¹  
    1. ICD-10 Code for Alcohol abuse, uncomplicated- F10.10- Codify by AAPC

    

    www.aapc.com

  • F43.21(Adjustment disorder with depressed mood) if clinically appropriate.
• Billing Code:
  • Documentation must clearly justify the level of service provided. This includes:
    • A detailed mental status exam.
    • A thorough suicide risk assessment.
    • Documentation of the crisis intervention.
    • The time spent with the patient.
    • Document the patients access to firearms.
    • Document the patients stated plan.
    • Document the patients stated intent.

3. Pertinent Documentation Missing:

• Detailed history of alcohol use (frequency, duration, withdrawal symptoms).
• Specific details about the suicide plan (access to firearms, intent, timeline).
• History of previous suicide attempts.
• Details of his support system.
• Information on current medications and allergies.
• Details of sleep, appetite, and energy levels.
• A full past psychiatric history.
• More details about his current employment situation.
• Details about his relationship with his children.
• Details regarding his coping mechanisms.
• A physical examination.
• Information regarding any current medical conditions.

4. Legal and Ethical Dilemmas:

• Overbilling/Upcoding:
  • Assigning a higher-level code than the services provided is fraudulent. This can lead to legal penalties and damage to professional reputation.
  • Example: Billing for crisis intervention when the patient did not meet the criteria.
• Fraudulent Practices:
  • Falsifying documentation to justify higher reimbursement is illegal.
  • Example: Documenting a longer session time than actually occurred.
• Strategies for Promoting Ethical Practices:
  • Ongoing Education: Stay updated on coding and billing guidelines, and ethical standards.
  • Peer Review and Auditing: Implement regular chart reviews to identify and correct coding errors.
  • Promote an office culture of ethical behavior, and open communication.

5. Improving Documentation for Maximum Reimbursement:

• Be thorough and specific in documentation.
• Clearly link diagnoses to symptoms and findings.
• Document the time spent with the patient.
• Use standardized assessment tools when appropriate.
• Document all interventions and follow-up plans.
• When there is a change in the patients condition, document those changes.
• Always document the patients current mental status.
• Always document safety planning, and suicide risk assessments.
• Document all conversations with other providers, or family members.

By following these guidelines, you can ensure accurate coding, minimize legal and ethical risks, and maximize reimbursement.