A 99204/5 requires a comprehensive HPI, comprehensive exam, and a moderate/high MDM.
That breaks down to:
- a chief complaint
- an extended HPI
- 4 elements of HPI or status of 3 chronic or inactive problems
- Quality = mood
- Severity = mild,moderate, severe
- Context = what's causing it
- Duration = How long has it been going on
- Modifying factors = anything helped?
- 10 system ROS (Can be done by questionnaire and transferred to note). My favs are in bold.
Constitutional, Eyes, Ears/Nose/Mouth/Throat, Cardiovascular, Respiratory, Gastrointestinal, Genitourinary, Musculoskeletal, Integumentary, Neurological, Psychiatric, Endocrine, Hematologic/Lymphatic, Allergic/Immunologic
- Complete PFSH (Need 1 element from each. Can be prepopulated), Favs in Bold
- Medical Hx:
- Prior illnesses or injuries
- Prior operations
- Prior hospitalizations
- Current medications
- Allergies
- Age-appropriate immunization status
- Age appropriate feeding/dietary status
- Extra not for billing, but good to have: psychiatric diagnoses, past medications tried
- Family Hx:
- The (mental) health status or cause of death of parents, siblings and children
- Specific diseases related to problems identified in the Chief Compliant, HPI, or ROS
- Diseases of family members which may be hereditary or place the patient at risk
- Social Hx:
- Marital status and/or living arrangements
- Current employment
- Occupational history
- Use of drugs, alcohol or tobacco
- Level of education
- Sexual history
- Other relevant social factors
Exam:
- 3 of 7 VS (BP, Pulse, Respirations are easy for MA to get)
- one element of MSK (gait and station is easy)
- and psychiatric MSE
MDM: Moderate requires 3 problem points, 3 data points, and/or a moderate risk issue. High requires 4,4, and high respectively. You only need to meet the category in 2/3, and since there aren't many "data points" to review in psychiatry, the problems and thseverityty of the issue guide the code:
- Problems
- 1pt - self-limited or minor (limit 2)
- 2pts - established problem, stable or improving
- 2pts- established problem, worsening
- 3pts - New problem, with no additional work-up planned (maximum of 1)
- 4pts - New problem, with additional work-up planned
- Data points
- 1pt - Review or order clinical lab tests
- 1pt - Review or order radiology test
- 1pt - Review or order medicine test (PFTs, EKG, cardiac echo or cath)
- 1pt - Discuss test with performing physician
- 2pt - Independent review of image, tracing, or specimen
- 1pt - Decision to obtain old records
- 2pts - Review and summation of old records
- Severity
- Moderate: One or more chronic illness with mild exacerbation, progression, or side effects of treatment or two or more stable chronic illnesses or undiagnosed new problem with uncertain prognosis (e.g., psychosis)
- Severe: One or more chronic illnesses with severe exacerbation, progression, or side effect of treatment (e.g., schizophrenia) or acute illness with threat to life (e.g., suicidal or homicidal ideation)
- Total time face to face with patient
- "Greater than 50% of face time spent providing counseling and/or coordination of care
- Counselling provided:
- diagnostic results or impressions
- risks and benefits of treatment options
- instructions for management/treatment and/or follow-up
- importance of adherence to treatment
- risk factor reduction
- Family/caregiver education
- prognosis
- Patient/family response to intervention
- Coordination of care
- None
- family/caregiver
- PCP/outside medical staff
- School staff/probation
- Response/outcome of coordination if necessary
So...a full 99205 note might look like...
CC: "This is hard"
HPI:
Jane Doe is a 23yr old female who states she has been moderately depressed for the past week because she lost her job. She also endorses high levels of anxiety that have worsened with current stressors.
ROS:
- Constitutional: no fevers or weight loss
- Cardiovascular: no palpitations or chest pain
- Respiratory: no SOB or cough
- Gastrointestinal: no nausea or diarrhea
- Musculoskeletal: no joint or muscle ache
- Integumentary: No rashes
- Neurological: No headache
- Psychiatric: depressed, anxious
- Endocrine: No hot flashes
- Immunologic: No recent illnesses
Med/Psych/Family/Social Hx:
- Appendectomy at age 14
- 3 admissions to Local Psychiatric hospital for SI/SA
- Current Meds: Zoloft 25mg
- Allergies: none
- Mother: Depression
- Drugs: Occasional alcohol use
Exam
- BP 120/80, HR 82, RR 14
- Gait/station wnl
- MSE
- Appearance: young caucasian female wearing jeans and t-shirt, well groomed
- Behavior: Mild psychomotor agitation
- Cooperation: disclosing, fair eye contact
- Speech: normal rate, normal rhythm, normal prosody
- Thought process: circumstantial
- Thought content: focused on stressors. Denies SI, able to contract for safety. No HI. No hallucinations
- Mood: "Terrible"
- Affect: Downcast, full range, non-labile, congruent to mood
- Perceptions: intact
- LOC/Knowledge: appears adequate
- Insight: fair
- Judgment: fair
Assessment
- Unspecified mood disorder
- unspecified anxiety disorder
- Cluster B traits
Plan
- Increase Zoloft to 50mg daily
- Provided supportive therapy
- Refer to psychology for continued therapy
MDM Risk: High
Total time face to face with patient was 60mins
Greater than 50% of face time spent providing counseling and/or coordination of care
Counselling provided:
- Diagnostic results or impressions
- Risks and benefits of treatment options
- Instructions for management/treatment
- Importance of adherence to treatment
- Risk factor reduction
- Prognosis
Patient/family response to intervention:
She agreed with the assessment and prognosis as discussed. She understood the need for continued treatment and therapy. She agreed with the medication changes and understood the need adherence. She understood the need for interventions to reduce further harm.
Coordination of care
- PCP/outside medical staff: Referral placed
Response/outcome of coordination if necessary:
- Pending approval for outside therapy
This note documented everything necessary. With an EMR that pre-populates much of the data and allows a drop down for the MSE, this would take <5mins to write. Of course, if the nature of the conversation needs some CYA extra stuff that's fine, but I think this sparse, mostly EMR generated, almost useless note to get paid appropriately lets you actually sit and talk with the patient.
