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APNA 27th Annual Conference Session 1025: October 9, 2013

Cadena 1

Sandra J. Cadena, PhD, APRN

CPT WorkGroup - APNA Representative

[email protected]

1

Review the DSM-5 changes & additionsDescribe the 2013 revisions to the

Current Procedural Terminology (CPT) codes

CPT codes for billing & documentation purposes in PMH nursing practice

E/M codes & psychiatry/mental health

2

2013Diagnostic

and

Statistical

Manual,

5th Edition

3

APA’s goal in developing DSM-5 is an evidence-based manual

Useful to clinicians -accurately diagnose mental disorders.

Decisions to include a diagnosis in DSM-5-based on scientific advances in research underlying the disorder

Collective clinical knowledge of experts in the field.

4

Changes in DSM-5 were made to better characterize symptoms & behaviors of groups of people who are currently seeking clinical help but whose symptoms were not well defined by DSM-IV.

More accurately defining disorders, diagnosis and clinical care will be improved

New research will be facilitated to further understanding of mental disorders.

5

Assessment and diagnosis of mental disorders

Does not include information or guidelines for treatment of any disorder

Will be helpful in measuring the effectiveness of treatment

Dimensional assessments will assist clinicians in assessing changes in severity levels as a response to treatment.

6


Cadena 2

Companion publications

Most up-to-date criteria for diagnosing mental disorders

Extensive descriptive text

Providing a common language

ICD contains code numbers used in DSM-5 and all of medicine,

Needed for insurance reimbursement

Monitoring of morbidity & mortality statistics by national and international health agencies

7

SECTION I

DSM-5

Basics

8

Introduction Historical development Dimensional approach Clustering of disorders

-Internalizing factors -Externalizing factors

Developmental and lifespan considerations Disorder & Function - Multiaxial system

Use of the Manual

Cautionary Statement for Forensic Use of DSM-5

9

Eliminated Axis I, II and III combined Principal diagnosis

Listed first Primary focus Remaining diagnoses listed in order of focus &

treatment

Axis IV ICD-9-CM V codes ICD-10 Z codes

Axis V Consider mental diagnosis or symptom status

separate from functional/disability status

10

Clinical case formulation

Clinical significance

Separate disorders and function/disability

Elements of a diagnosis

11

Subtypes Mutually exclusive subgroupings within a

diagnosis “Specify whether” in the criteria set Can be coded in the 4th, 5th or 6th digit

12


Cadena 3

Not intended to be mutually exclusive

More than 1 specifier can be given

“Specify” or “Specify if”

i.e., Major depressive disorder with mixed features

‘Severity’ specifiers

Intensity, duration, frequency

i.e., in partial remission

‘Descriptive features’ specifiers

i.e., with poor insight

13

SECTION II

Diagnostic

Criteria

and Codes

14

Neurodevelopmental Disorders

Schizophrenia Spectrum and Other PsychoticDisorders

Bipolar and Related Disorders

Depressive Disorders

Anxiety Disorders

Obsessive‐Compulsive and Related Disorders

Trauma‐ and Stressor‐Related Disorders

Dissociative Disorders

Somatic Symptom and Related Disorders15

Feeding and Eating Disorders Elimination Disorders Sleep‐Wake Disorders Sexual Dysfunctions Gender Dysphoria Disruptive, Impulse‐Control, and Conduct Disorders Substance‐Related and Addictive Disorders Neurocognitive Disorders Paraphilic Disorders Personality Disorder Other Mental Disorders Medication‐Induced Movement Disorders and Other

Adverse Effects of Medication Other Conditions That May Be a Focus of Clinical Attention

16

The phrase “general medical condition” is replaced inDSM‐5 with “another medical condition” where relevantacross all disorders.

NOS (not otherwise specified)‐ eliminated Other specified disorder Unspecified disorder

17

Intellectual Disability

(Intellectual Developmental Disorder)

Diagnostic criteria for intellectual disability (intellectualdevelopmental disorder) emphasizes the need for anassessment of both cognitive capacity (IQ) and adaptive functioning.

Severity is determined by adaptive functioning ratherthan IQ score.

18


Cadena 4

The DSM‐5 communication disorders include language disorder (which combines DSM‐IV expressive andmixed receptive‐expressive language disorders),

speech sound disorder ( new name for phonologicaldisorder),

childhood‐onset fluency disorder (new name forstuttering).

Also included is social (pragmatic) communicationdisorder, new condition for persistent difficulties in thesocial uses of verbal & nonverbal communication.

**

19

A new diagnosis of Social (Pragmatic) Communication Disorder has been added to the DSM-5. It is indicated when there is impaired communication, but does not qualify at the level of autism.

True

False

20

TRUE

21

New DSM‐5 name ASD now encompasses the previous DSM‐IV autisticdisorder (autism), Asperger’s disorder, childhooddisintegrative disorder, & pervasive developmentaldisorder not otherwise specified. ASD characterized by‐ 1) deficits in social communication & social interaction 2) restricted repetitive behaviors, interests, & activities

(RRBs). Both components required for diagnosis of ASD, socialcommunication disorder is diagnosed if no RRBs present.

22

Diagnostic criteria for attention‐deficit/hyperactivitydisorder (ADHD) in DSM‐5 are similar to Specific Learning Disorder

Combines the DSM‐IV diagnoses of reading disorder, mathematics disorder, disorder of writtenexpression, and learning disorder not otherwise specified.

23

developmental coordination disorder stereotypic movement disorder Tourette’s disorder persistent (chronic) motor or vocal tic disorder provisional tic disorder, other specified tic disorder, unspecified tic disorder.

**

24


Cadena 5

Autism Spectrum Disorder (ASD) includes Asperger’s Disorder only.

True

False

25

FALSE

26

Schizophrenia, Schizoaffective Disorder, Delusional Disorder, Catatonia Two changes made to DSM‐IV Criterion A forschizophrenia.

2 Criterion A symptoms are required for anydiagnosis of schizophrenia.

27

The second change is the addition of a requirement in Criterion A‐

individual must have at least one of these threesymptoms: delusions, hallucinations, anddisorganized speech.

At least one of these core “positive symptoms” is necessary for a reliable diagnosis of schizophrenia.

28

The DSM‐IV subtypes of schizophrenia (i.e., paranoid, disorganized, catatonic,undifferentiated, and residual types) areeliminated.

29

The primary change to schizoaffective disorderis the requirement that

a major mood episode be present for amajority of the disorder’s total duration after Criterion A has been met.

30


Cadena 6

Criterion A for delusional disorder no longer has the requirement that the delusions must be non‐bizarre.

Exclusion criterion‐ demarcation of delusional disorder from psychotic variants of obsessive‐compulsive disorderand body dysmorphic disorder which states that the symptomsmust not be better explained by these conditions with absent insight/delusional beliefs

31

The same criteria are used to diagnose catatoniawhether the context is a psychotic, bipolar, depressive, or other medical disorder, or an unidentified medical condition.

DSM‐IV ‐ 2 of 5 symptom clusters were required if the context was a psychotic or mood disorder, whereas only one symptom cluster was needed if the contextwas a general medical condition.

32

DSM‐5 ‐ all contexts require three catatonicsymptoms (from a total of 12 characteristicsymptoms).

Catatonia may be diagnosed as a specifier fordepressive, bipolar, & psychotic disorders; as aseparate diagnosis in the context of another medicalcondition; or as an ‘other specified’ diagnosis.

**

33

The subtypes of schizophrenia are included in the DSM-5.

True

False

34

FALSE

35

Bipolar Disorders

Criterion A for manic and hypomanic episodes now includes an emphasis on changes in activity and energy as well as mood.

DSM‐IV diagnosis of bipolar I disorder, mixedepisode, requiring that the individual simultaneously meet full criteria for both mania and major depressive episode, has been removed. New specifier, “with mixed features”

36


Cadena 7

Bipolar and related disorders and depressivedisorders, a specifier for anxious distress isdelineated.

This specifier is intended to identify patientswith anxiety symptoms that are not part of thebipolar diagnostic criteria.

37

DSM‐5 contains several new depressive disorders‐ Disruptive mood dysregulation disorder Premenstrual dysphoric disorder Disruptive mood dysregulation disorder

DSM‐IV – dysthymia

DSM‐5 ‐ persistent depressive disorder ‐‐chronic major depressive disorder and dysthymic disorder.

MDD ‐ same

**

38

Which of the following changes are made by the DSM-5 for bipolar disorder?

1. Increased activity has been added to Criterion A.

2. Bipolar disorder, mixed features now requires a patient to simultaneously meet full criteria for mania and major depression.

3. Energy level is not considered in DSM-5.

39

1. Increased activity has been added to Criterion A.

2. Bipolar disorder, mixed features now requires a patient to simultaneously meet full criteria for mania and major depression.

3. Energy is not considered in DSM-5. FALSE

40

DSM‐IV – exclusion criterion for a major depressive episode applied to depressive symptoms lasting less than 2 months followingdeath of a loved one.

This exclusion is omitted in DSM‐5

removes the implication that bereavementtypically lasts only 2 months

recognized as a severe psychosocial stressor.

41

Agoraphobia, Specific Phobia, & Social Anxiety Disorder (Social Phobia)

Deletion of the requirement that individuals over age 18 years recognize that their anxiety is excessive or unreasonable.

The 6‐month duration, limited to individuals under age 18 in DSM‐IV, now extended to all ages.

42


Cadena 8

Essential features of panic attacks remain unchanged New terms‐”unexpected” and “expected” panic attacks.Panic attack can be listed as a specifierapplicable to all DSM‐5 disorders.

43

Panic disorder and agoraphobia are unlinkedin DSM‐5.

DSM‐IV ‐diagnoses of panic disorder with agoraphobia, panic disorder without agoraphobia, and agoraphobia without historyof panic disorder

DSM‐5 two diagnoses

panic disorder

agoraphobia

44

Specific Phobia Social Anxiety Disorder (Social Phobia) Separation Anxiety Disorder SelectiveMutism

45

DSM‐5 new disorders include:

Hoarding disorder

Excoriation (skin‐picking) disorder

Substance/medication‐induced obsessive‐compulsive and related disorder

Obsessive‐compulsive and related disorderdue to another medical condition

46

DSM‐IV diagnosis of trichotillomania DSM‐5 trichotillomania (hair‐pulling disorder)

DSM‐IV classification ‐ impulse‐control disorders notelsewhere classified

DSM‐5 ‐ obsessive‐compulsive and relateddisorders

**

47

It is acceptable to diagnose a patient with a panic disorder with or without agoraphobia.

True

False

48


Cadena 9

FALSE

49

Acute Stress Disorder

DSM-5, the stressor criterion (Criterion A) for acute stress disorder -changed from DSM-IV.

The criterion requires being explicit as to whether qualifying traumatic events were experienced directly, witnessed, or experienced indirectly.

DSM-IV (Criterion A2) regarding the subjective reaction to the traumatic event (e.g., “the person’s response involved intense fear, helplessness, or horror”) eliminated.

DSM-5 for acute stress disorder -exhibit any 9 of 14 listed symptoms in these categories: intrusion, negative mood, dissociation, avoidance, and arousal.

50

DSM‐5 criteria for posttraumatic stress disorder (PTSD) differsignificantly from those in DSM‐IV. DSM‐IV ‐three major symptom clusters—re‐experiencing,avoidance/numbing, and arousal— DSM‐5 ‐ 4 symptom clusters Avoidance/numbing cluster divided into 2 distinct clusters:

Avoidance Persistent negative alterations in cognitions and mood.

Alterations in arousal and reactivity— Includes irritable or aggressive behavior & reckless or self‐destructive behavior

**

51

DSM-5 PTSD criteria may include that the sufferer learns about a traumatic event vs. the prior requirement (DSM-IV) that the event actually be witnessed or experienced.

True

False

52

TRUE

53

DSM-5, somatoform disorders now referred to as somatic symptom and related disorders.

Diagnoses removed- somatization disorder hypochondriasis pain disorder undifferentiated somatoform disorder

54


Cadena 10

Includes oppositional defiant disorder; conduct disorder; and disruptive behavior disorder not otherwise specified.

DSM‐5 ‐categorized as ‘other specified’ and ‘unspecified’disruptive, impulse‐control, and conduct disorders; intermittent explosive disorder, pyromania, &kleptomania.

These disorders are all characterized by problems inemotional and behavioral self‐control.

55

Gambling Disorder

DSM‐5 ‐ not separate diagnoses of substanceabuse and dependence as in DSM‐IV.

DSM‐5 substance use disorder criteria arenearly identical to the DSM‐IV substance abuse and dependence criteria combined into a singlelist, with two exceptions.

56

DSM‐IV recurrent legal problems criterion forsubstance abuse has been deleted from DSM‐5

DSM‐5 (new) craving or a strong desire orurge to use a substance.

DSM‐5 (new) Cannabis withdrawal Caffeine withdrawal

57

Delirium Criteria for delirium have been updated & clarified on

currently available evidence.

Major and Mild Neurocognitive Disorder (NCD) The DSM‐IV diagnoses of dementia and amnestic disorder aresubsumed under newly named entity

DSM‐5 ‐ less severe level of cognitive impairment, mild NCD

**

58

The diagnosis of mild neurocognitive disorder should include a subtype ‘specify whether’ due to:

True

False

59

TRUE

60


Cadena 11

The criteria for personality disorders in Section II of DSM‐5 have not changed from DSM‐IV.

Alternative approach to the diagnosis of personality disorders was developed for DSM‐5 for further study in Section III.

61

SectionIII

Emerging

Measures

and

Models

62

Genetic and neurobiological findings may make the current categorical schema less important,

recognizing instead common symptoms that occur across all disorders &

varying ways in which individual patients may present.

63

Assessment MeasuresCultural FormulationAlternative Model for Personality DisordersConditions for Further Study

64

Cross‐Cutting SymptomMeasures Self‐Rated DSM‐5 Level 1 Cross‐Cutting Symptom

Measure—Adult

Parent/Guardian‐Rated DSM‐5 Level 1 Cross‐Cutting Symptom Measure—Child Age 6–17

Clinician‐Rated Dimensions of Psychosis SymptomSeverity

65

World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0)

Include measures of impairment and disability

This tool, like the cross-cutting symptom measures, is especially amenable to use with EHRs.

66


Cadena 12

Culture‐systems of knowledge, concepts, rules and practices that are learned and transmitted across generations.

Cultural Formulation Interview (CFI) 16 questions – impact of culture on keyaspects of clinical presentation & care

Cultural Formulation Interview (CFI)—Informant Version

Glossary of Cultural Concepts of Distress

67

Characterized by impairments in personality functioning pathological personality traits

68

Attenuated Psychosis Syndrome Depressive Episodes With Short Duration

Hypomania Persistent Complex Bereavement Disorder

Internet Gaming Disorder Neurobehavioral Disorder Associated

With Prenatal Alcohol Exposure Suicidal Behavior Disorder Non‐suicidal Self‐Injury Caffeine Use Disorder

69

Highlights of Changes From DSM-IV to DSM-5 Glossary of Technical Terms

Glossary of Cultural Concepts of Distress

Alphabetical Listing of DSM-5 Diagnoses and Codes (ICD-9-CM and ICD-10-CM) Numerical Listing of DSM-5 Diagnoses and Codes (ICD-9-CM)

Numerical Listing of DSM-5 Diagnoses and Codes (ICD-10-CM) DSM-5 Advisors and Other Contributors

70

71

CURRENT

PROCEDURAL

TERMINOLOGY

CPT

72


Cadena 13

Diagnostic Psychotherapy Psychotherapy with E/MOther PsychotherapyOther Psychiatric Services

73

Service CPTCode

2013Change

Diagnosticinterviewexamination

90801 DELETED

Interactivediagnosticinterview

examination

90802 DELETED

74

Diagnostic evaluation(no medical)

90791 WHEN APPROPRIATE

Diagnostic evaluationwith medical

90792 WHEN APPROPRIATE

Diagnostic evaluation(no medical)

90791 YES

Diagnostic evaluationwith medical

90792 YES

75

Service CPT Code 2013 ChangeIndividual

psychotherapy 20-30

minutes

90804, 90816

45-50 minutes 90806, 90818 DELETED

75-80 minutes 90808, 90821

Interactive individual

psychotherapy 20-30

minutes

90810, 90823 DELETED

45-50 minutes 90812, 90826

75-80 minutes 90814, 90828

76

Service CPT CodeChange

Report withInteractivecomplexity (+90785)

Psychotherapy30 minutes

(16 to 37 minutes)

90832

45 minutes

(38 to 52 minutes)

90834 When appropriate

60 minutes(53+ minutes)

90837

77

Service CPT CodeChange

Report with Interactivecomplexity (+90785)

InteractivePsychotherapy 30minutes

(16 to 37 minutes)

90832 Yes

45 minutes

(38 to 52 minutes)90834 Yes

60 minutes(53+ minutes) 90837 Yes

78


Cadena 14

Service CPT Code 2013 ChangeIndividualpsychotherapy withE/M 20-30 minutes

90805, 90817

45-50 minutes 90807, 90819 DELETED

75-80 minutes 90809, 90822

Interactive individualpsychotherapy 20-30minutes

90811, 90824 DELETED

45-50 minutes 90813, 90827

75-80 minutes 90815, 9082979

Service Code Report with interactive complexity(+90785)

E/M + psychotherapyAdd on

E/M code selected (key components not time) and 1 of:+ 90833 (30 mins)+90836 (45 mins)+90838 (60 mins)

When appropriate

Yes

80

Service CPT Code 2013 Change

Familypsychotherapy

90846, 90847,90849

RETAINED

Grouppsychotherapy

90853 RETAINED

Interactive group

psychotherapy

90857 DELETED

81

Service CPT Code Report with interactivecomplexity (+90785)

Psychotherapy forcrisis

90839, +90840

NO

Family psychotherapy 90846,90847, 90849

NO

Group psychotherapy 90853 When appropriate

Interactive group

psychotherapy90853 Yes

82

Service Code 2013Change

Pharmacologicmanagement

90862

90863

DELETED

Prescribing psychologists only

83

Service Code Report withinteractivecomplexity(+90785)

Evaluation andmanagement

E/M code No

84


Cadena 15

85

E/M

E/M Alone

Outpatient:

99204,05,12,13,14,15

Inpatient:

99222,23,31,32,33

E/M PLUS Psychotherapy

86

Psychotherapy

Psychoanalysis

90845

Family Therapy

Pt present, not present,group

Psychotherapy

Time: 30,45, 60 minutes

87

30 (16-37*) minutes

45 (38-52*) minutes

60 (53+*) minutes

E/M Code and 90833

E/M Code and 90836

E/M Code and 90838

88

89

Start with a “99‐‐‐”

Used to document what happens in a patient encounter‐rendering a medical service

Evaluation (collecting and assessing information) and

Management (planning treatment or further assessment; prescribing medication)

Used by all other medical providers

90


Cadena 16

New Patient New to practice

Not seen in the past 3 years

Established Patient Ongoing relationship with the practice

Have seen in the past 3 years

If you are covering for another provider, the patient is considered seen

91

History

Physical exam

Medical decision‐making

Always start with medical decision‐making to determine the extent of history and physical exam you will need to do

92

1. Number of diagnoses or management options• Based on problem points chart developed for audit

purposes because language is so ambiguous

2. Amount of complexity of data• Based on data points chart developed for audit

purposes because language is so ambiguous

3. Risk of significant complications, morbidity, and/or mortality

93

• Based on– Number and types of problems– Complexity of establishing a diagnosis– Management decisions

• Influenced by– Undiagnosed problems– Number and type of tests– Need to seek advice from others– Problems worsening or failing to respond

94

Category of Problems/Major New symptoms

Points per problem

Self-limiting or minor (stable, improved, or worsening) (max=2)

1

Established problem (to examining physician); stable or improved

1

Established problem (to examining physician); worsening 2

New problem (to examining physician); no additional workup or diagnostic procedures ordered (max=1)

3

New problem (to examining physician); additional workup planned*

4*Additional workup does not include referring patient to another physician for future care

95

Level Total Data Points

Minimal 0-1

Limited 2

Multiple 3

Extensive 4

96


Cadena 17

• Based on– Types of diagnostic tests– Need to obtain records– Need to obtain history from other sources

• Influenced by– Unexpected findings– Independent interpretation of images, specimens, etc– Discussion of results with physician performing test

97

Categories of Data to be Reviewed (max=1 for each)

Points

Review and/or order of clinical lab tests 1

Review and/or order of tests in the radiology section of CPT 1

Review and/or order of tests in the medicine section of CPT 1

Discussion of test results with performing physician 1

Decision to obtain old records and/or obtain history from someone other than patient

1

Review and summarization of old records and/or obtaining history from someone other than patient and/or discussion of case with another health care provider

2

Independent visualization of image, tracing, or specimen itself (not simply review report)

2

98

Level Total Data Points

Minimal or none 0-1

Limited 2

Multiple 3

Extensive 4

99

• Based on– Presenting problem– Diagnostic procedure– Management options

• Influenced by– Co-morbidities, underlying conditions, risk factors– Uncertain prognosis, exacerbations, complications– Decision to order prescription drugs, IV meds– Decision to perform invasive tests, procedures, major

surgery

100

Level of Risk

Presenting Problems Diagnostic Procedure

Management Options Selected

Minimal Risk

• One self-limited or minor problem, e.g., dysthymia well-managed

• Laboratory tests

• Chest X-rays• EKG/EEG• Urinalysis

• Rest• Stay home

from school

Low Risk

• Two or more self-limited or minor problems;

• One stable chronic illness;• Acute uncomplicated

illness

• Physiologic tests not under stress, e.g., PFTs

• Glucosemonitoring

• OTC drugs

101

Level of Risk *

Presenting Problems Diagnostic Procedure

Management Options Selected

Mod Risk

• One or more chronic illnesses with mild exacerbation,

• progression, or side effects;• Two or more stable chronic

illnesses;• Undiagnosed new problem with

uncertain prognosis;• Acute illness with systemic

symptoms

• None that would be done in out-patientpsychiatry!

• Prescription drug management

High Risk

• One or more chronic illnesses with severe exacerbation,progression, or side effects;

• Acute or chronic illnesses that pose a threat to life or bodilyfunction

• None that would be done in out-patient psychiatry!

•Drug therapy requiringintensive monitoring fortoxicity (clozapine)

102


Cadena 18

# Diagnoses or Management Options

Amount and/or Complexity of Data to be Reviewed

Risk of Complications and/or morbidity/ mortality

DESIGNATED LEVEL OF MEDICAL DECISION-MAKING

Minimal [0-1 problem points

Minimal or none[0-1 data points]

Minimal STRAIGHTFORWARD99202-99212

Limited [2 problem points]

Limited [2 data points]

Low LOW COMPLEXITY99203-99213

Multiple[3 problem points]

Multiple[3 data points]

Moderate MOD COMPLEXITY99204-99214

High complexity[4 problem points]

Extensive[4 data points]

Extensive HIGH COMPLEXITY99205-99215

Requires 2 out of 3 areas in the outpatient office setting

103

• Assessment, impression, diagnosis

• Status of established diagnosis

• Differential diagnosis, probable, etc for undiagnosed (rule-outs)

• Initiation/changes in treatment

• Referrals, request, advice

• Type of tests

• Review and findings of tests

• Relevant findings from records

• Discussion of test results

• Direct visualization of specimens, images, etc

• Comorbidities/underlying conditions

• Type of surgical or invasive procedure

104

Chief Complaint (CC)

History of Present Illness (HPI)

Review of Systems (ROS)

Past, Family, Social History (PFSH)

105

Document in patient’s own words

“My moods make me feel like I’m always in a storm.”

106

• 8 Descriptors– Location (emotional & behavior are types of location in

psychiatry)– Quality (description of symptom i.e. sadness)– Severity– Duration– Timing– Context– Modifying Factors– Associated signs/symptoms

107

The patient reportscontinual1 emotional2

problems of moderate3

anxiety4 starting with theFailure from college5 two weeks ago6, now does not want to live in the same house with parents7 andassociated with disruptedsleep, loss of appetite & suicidal thoughts8.

1. Location 2. Quality 3. Severity4. Duration5. Timing6. Context7. Modifying Factors8. Associated

signs/symptoms

108


Cadena 19

Levels of History of Present IllnessBrief 1-3 elements OR

Status of 1-2 chronic or inactive conditions

Extended 4 or more elements ORStatus of 3 or more chronic or inactive conditions

1. Location 2. Quality3. Severity 4. Duration

5. Timing6. Context7. Modifying Factors8. Associated Signs/Symptoms

109

Past history Current medications Illnesses and injuries Operations and hospitalizations Allergies Treatments Dietary status Age appropriate immunizations

Family history Medical events in patient’s family r/t CC, HPI, ROS

Hereditary or high risk diseases Health status or cause of death of parents, siblings, children

Social History Marital status

Living arrangements

Occupational history

Use of drugs, alcohol, tobacco

Extent of education

Sexual history

Current employment

Other

110

Levels of PFSH

Pertinent 1 item from 1 of 3 areas

Complete New Patient: 3 out of 3 areasEstablished Patient: 2/3 areas

111

1. Constitutional

2. Eyes

3. Cardiovascular

4. Neurological

5. Genitourinary

6. Ears, nose, throat, mouth

7. Gastrointestinal

8. Integumentary (skin and/or breast

9. Musculoskeletal

10. Psychiatric

11. Hematologic/lymphatic

12. Respiratory

13. Endocrine

14. Allergic/immune

112

Review of Systems Requirements

Problem pertinent:

System directly related to the problem(s) identified in the HPI

Extended: 2‐9 systems

Complete: 10 or more systems •Document individually systems with positive or pertinent negative responses•“All other systems reviewed & are negative”is permissible •In the absence of such a notation, at least 10 systems must be individually documented

113

HPI PFSH ROS TYPE

Brief: 1-3 elements or 1-2 chronic conditions

N/A N/A Problem-focused99202/99212

Brief: 1-3 elements or 1-2 chronic conditions

N/A Problem Pertinent

1

Expanded problem-focused

99203/99213

Extended: 1-3 elements or 1-2 chronic conditions

Pertinent1 element*

Extended2-9

systems

Detailed99204/99214

Extended: 4 elements or 3 chronic conditions

Complete3 elements**

Complete10-14

systems

Comprehensive99205/99215

*No PFSH required with subsequent hospital visits**2 elements for established patients 114


Cadena 20

115

1. Cardiovascular

2. Ears, nose, mouth and throat

3. Eyes

4. Genitourinary (female)

5. Genitourinary (male)

6. Hematologic, Lymphatic, Immunologic

7. Musculoskeletal

8. Neurological

9. Psychiatric

10. Respiratory

11. Skin

116

Comprised of the following systems Constitutional

Musculoskeletal

Psychiatric

117

• Measurement of any 3 of the 7 vital signs: —B/P__ sitting or standing, —B/P__ supine, —P__, —R__, —T__, —Ht__ —Wt__

• General appearance‐grooming, deformities• Development• Nutrition

118

Assessment of muscle strength and tone (e.g. flaccid, cog wheel, spastic,) with notation of any atrophy and abnormal movements e.g. motor tics, tremors, vermiform tongue movements

Examination of gait and stations

119

Description of speech: rate; volume; articulation; coherence; spontaneity with notation of abnormalities (perseveration, paucity of language)

Description of thought processes: rate of thoughts; content of thoughts (logical vs. illogical, tangential); abstract reasoning; computation

Description of associations (loose, tangential, circumstantial, intact)

Description of abnormal or psychotic thoughts: hallucinations; delusions; preoccupation with violence; homicidal or suicidal ideation; obsessions

Description of judgment: (concerning everyday activities and social situations) and insight (concerning psychiatric condition)

120


Cadena 21

• Orientation to time, place and person

• Recent and remote memory

• Attention span and concentration

• Language (naming objects, repeating phrases)

• Fund of knowledge (awareness of current events, past history, vocabulary)

• Mood and affect (depression, anxiety, agitation, hypomania, lability)

121

Elements of Examination Level

1-5 elements Problem-focused99202, 99212

At least 6 elements Expanded problem-focused99202, 99213

At least 9 elements Detailed99203, 99214

Perform all elements Comprehensive99204, 99215

122

123

OFFICE OR OTHER OUTPATIENT SERVICES: New or Established

99201/99211 99202/99212 99203/99213 99204/99214 99205/99215

HISTORY

CC Required Required Required Required Required

HPI 1‐3 elements 1‐3 elements 4+ elements 4+elements 4+ elements

ROS N/A Pertinent 2‐9 systems 10‐14

systems

10‐14

systems

PFSH N/A N/A 1/3 elements 3/3 elements 3/3 elements

PHYSICAL EXAM

1‐5 elements 6‐8 elements 9 or more

elements

Comprehensi

ve

Comprehensi

ve

MEDICAL COMPLEXITY DECISION MAKING

SF SF LOW MODERATE HIGH

124

EVALUATION AND MANAGEMENT NEW PATIENT OFFICE PROGRESS NOTE Client Name:___________________________ Date of Service:_______________ Provider Name:______________________Time In:_____________am/pm Time Out:________________ am/pm Total Time Spent (minutes):_____________________Level of Service: 99202______ 99203______99204______99205_____ COUNSELING/COORDINATION>50% of time (explain)______________________________________________________________________________________________________________________________CHIEF COMPLAINT:

PFSH No Chng See Note

Past □ □

Family □ □

Social □ □99202-PROBLEM FOCUSED=NONE 99203-EXPANDED PROBLEM FOCUSED=NONE 99204-DETAILED=At Least 1 Item From 1 Category 99205-COMPREHENSIVE Specifics of at Least Two Items

EXAM-Single System 2 BULLETS NL See Note EXAM –Single System 2 BULLETS NL See Note

3 out of 7 Constitutional □ □ Musculoskeletal □ □Blood Pressure: Gait and station □ □

Pulse: Muscle strength or tone, atrophy, □ □abnormal movements (e.g. flaccid, cog wheel)Temperature:

Respiration:

Height: Note:

Weight:

General appearance of patient □ □

(e.g. development, nutrition, body habits, deformities, □Well Groomed □ Disheveled □ Bizarre □

Inappropriate

Note:

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• www.PsychiatryOnline.org• 2013 CPT Coding Manual• AACAP online webinars permission granted to APNA• E/M University Online:

http://emuniversity.com/Curriculum_Free.html• Medicare learning network:

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/eval_mgmt_serv_guide-ICN006764.pdf

• APNA Webinars• Mary Moller, PhD, APRN• Eileen Carlson, RN, JD

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Cadena 22

October 7th revisions-

http://www.dsm5.org/Documents/IMPORTANT%20CODING%20CORRECTIONS%20FOR%20DSM-5%2010-7-13.pdf

Assessment measures (online)

http://www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures

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Thank you!!!

[email protected]

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