But that example is most suitable for psychopharm or psychotherapy of low frequency. I've been trying to figure out what to do for my psychoanalysis patients, who I see 4 times per week.
This is my attempt at 2 such notes for the same patient. I'll include the Monday note in this post, and the Tuesday note in my next post:
Name: Socrates DOB: 469 BCE Date of Service: 11.26.12
Start time: 2:30pm Stop Time: 3:15pm. Total Face Time: 45 minutes
CPT: 90836, E/M ?????
CC: F/U for "Self Knowledge"
Interval History: The patient expressed conflict over homosexual impulses. He also c/o increasing obsessional thoughts over the weekend, in which he worries about being poisoned, and checks his food and drink 4-5 times before partaking of them. He is increasingly argumentative, particularly with authority figures.
ROS: Patient reports increased checking behavior, as well as insomnia.
PFSH: Patient has difficult relationship with his wife.
PME:
- Speech-Greek
- Thought processes-logical
- Thought Content: Obsessional thinking and compulsive checking
- Affect: Anxious
- General Appearance: Wearing toga
- Other: Uses intellectualization and reaction formation as defenses
Dx: Anxiety NOS, consider OCD
Current Meds: none
Labs: Ordered-none; reviewed-none
Allergies: Hemlock
Psychotherapy Note: Interpreted patient's defenses, encouraged less intellectualization, and further exploration of his emotional life.
Plan:
Continue psychoanalysis 4x/week
Now to determie the E/M code:
The Interval History includes 4 elements:
- Severity- "Increasing" and checking 4-5 times
- Timing-"Over the weekend"
- Context-"With authority figures"
- Associated Syptoms-Checking
So this is an extended Interval History.
The ROS includes 1 system-Psychiatric.
And the PFSH includes 1 element of Social History.
Looking at Table 2, History, from my last post:
Level of Hx
|
HPI
|
ROS
|
PFSH
|
Problem Focussed
|
Brief
|
None
|
None
|
Extended Problem Focussed
|
Brief
|
1 System
|
None
|
Detailed
|
Extended
|
2 Systems
|
1
|
Since 3 out of 3 elements are needed for History, this note would have an
Extended Problem Focussed History.
Next is the Psychiatric Exam, which includes 6 elements.
And finally, the MDM.
Since obsessional thoughts are an established problem that is worsening, this would earn 2 problem points.
In addition, since the patient is increasingly argumentative, that is another established problem that is worsening, worth another 2 points. So there are a total of 4 problem points.
There are 0 data points, since I didn't review labs or call anyone etc.
And the Level of Risk is moderate, since there are one or more established conditions that are worsening. I don't think I can call this a "severe exacerbation", but if I could, then the level of risk would be high.
Looking at the Table for MDM, we have:
Overall MDM
|
Problem Points
|
Data Points
|
Risk
|
Straightforward
|
1
|
1
|
Minimal
|
Low Complexity
|
2
|
2
|
Low
|
Moderate Complexity
|
3
|
3
|
Moderate
|
High Complexity
|
4
|
4
|
High
|
Since only 2 out of 3 elements are needed for MDM, this would qualify as Moderate Complexity.
Finally, summing it all up :
Level Of Care Requirements (2 out of 3 needed)
Level of Care
|
Hx
|
Exam
|
MDM
|
99212
|
Problem Focussed
|
1-5
|
Straightforward
|
99213
|
Extended Problem Focussed
|
>6
|
Low Complexity
|
99214
|
Detailed
|
12 from 2 or more organ systems
|
Moderate Complexity
|
99215
|
Comprehensive
|
2 from each of 9 organ systems
|
High Complexity
|
Ladies and Gentlemen, this is a 99213 note. Ta Da!