Sandra J. Cadena, PhD, APRN CPT WorkGroup - APNA Representative DrSJCadena@gmail.com Review the DSM-5 changes & additions Describe 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 1 2 2013 Diagnostic 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 1
SECTION I 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 DSM-5 Basics 7 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 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 9 10 Clinical case formulation Clinical significance Separate disorders and function/disability Elements of a diagnosis Subtypes Mutually exclusive subgroupings within a diagnosis Specify whether in the criteria set Can be coded in the 4th, 5th or 6th digit 11 12 Cadena 2
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 SECTION II Diagnostic Criteria and Codes Descriptive features specifiers i.e., with poor insight 13 14 Neurodevelopmental Disorders Schizophrenia Spectrum and Other Psychotic Disorders Bipolar and Related Disorders Depressive Disorders Anxiety Disorders Obsessive Compulsive and Related Disorders Trauma and Stressor Related Disorders Dissociative Disorders Somatic Symptom and Related Disorders 15 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 in DSM 5 with another medical condition where relevant across all disorders. NOS (not otherwise specified) eliminated Other specified disorder Unspecified disorder Intellectual Disability (Intellectual Developmental Disorder) Diagnostic criteria for intellectual disability (intellectual developmental disorder) emphasizes the need for an assessment of both cognitive capacity (IQ) and adaptive functioning. Severity is determined by adaptive functioning rather than IQ score. 17 18 Cadena 3
The DSM 5 communication disorders include language disorder (which combines DSM IV expressive and mixed receptive expressivelanguagedisorders), speech sound disorder ( new name for phonological disorder), childhood onset fluency disorder (new name for stuttering). Also included is social (pragmatic) communication disorder, new condition for persistent difficulties in the social uses of verbal &nonverbal communication. 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 ** 19 20 TRUE New DSM 5name ASD now encompasses the previous DSM IV autistic disorder (autism), Asperger s disorder, childhood disintegrative disorder, & pervasive developmental disorder not otherwise specified. ASD characterized by 1) deficits in social communication &socialinteraction 2) restricted repetitive behaviors, interests, & activities (RRBs). Both components required for diagnosis of ASD, social communication disorder is diagnosed if no RRBs present. 21 22 Diagnostic criteria for attention deficit/hyperactivity disorder (ADHD) in DSM 5 are similar to Specific Learning Disorder Combines the DSM IV diagnosesof reading disorder, mathematics disorder, disorder of written expression, and learning disorder not otherwise specified. 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. ** 23 24 Cadena 4
Autism Spectrum Disorder (ASD) includes Asperger s Disorder only. FALSE True False 25 26 Schizophrenia, Schizoaffective Disorder, Delusional Disorder, Catatonia Two changes made to DSM IV Criterion A for schizophrenia. 2 Criterion A symptoms are required for any diagnosis of schizophrenia. The second change is the addition of a requirement in Criterion A individual must have at least one of these three symptoms: delusions, hallucinations, and disorganized speech. At least one of these core positive symptoms is necessary for a reliable diagnosis of schizophrenia. 27 28 The DSM IV subtypes of schizophrenia (i.e., paranoid, disorganized, catatonic, undifferentiated, and residual types) are eliminated. The primary change to schizoaffective disorder is the requirement that a major mood episode be present for a majority of the disorder s total duration after Criterion A has been met. 29 30 Cadena 5
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 disorder and body dysmorphic disorder which states that the symptoms must not be better explained by these conditions with absent insight/delusional beliefs The same criteria are used to diagnose catatonia whether 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 context was a general medical condition. 31 32 DSM 5 all contexts require three catatonic symptoms (from a total of 12 characteristic symptoms). Catatonia may be diagnosed as a specifier for depressive, bipolar, & psychotic disorders; as a separate diagnosis in the context of another medical condition; or as an other specified diagnosis. The subtypes of schizophrenia are included in the DSM-5. True False ** 33 34 FALSE 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, mixed episode, requiring that the individual simultaneously meet full criteria for both mania and major depressive episode, has been removed. New specifier, with mixed features 35 36 Cadena 6
Bipolar and related disorders and depressive disorders, a specifier for anxious distress is delineated. This specifier is intended to identify patients with anxiety symptoms that are not part of the bipolar diagnostic criteria. DSM 5contains 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 ** 37 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. 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 39 40 DSM IV exclusion criterion for a major depressive episode applied to depressive symptoms lasting less than 2 months following death of a loved one. This exclusion is omitted in DSM 5 removes the implication that bereavement typically lasts only 2 months recognized as a severe psychosocial stressor. 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. 41 42 Cadena 7
Essential features of panic attacks remain unchanged New terms unexpected and expected panic attacks. Panic attack can be listed as a specifier applicable to all DSM 5 disorders. Panic disorder and agoraphobia are unlinked in DSM 5. DSM IV diagnoses of panic disorder with agoraphobia, panic disorder without agoraphobia, and agoraphobia without history of panic disorder DSM 5 two diagnoses panic disorder agoraphobia 43 44 Specific Phobia Social Anxiety Disorder (Social Phobia) Separation Anxiety Disorder Selective Mutism DSM 5 new disorders include: Hoarding disorder Excoriation (skin picking) disorder Substance/medication induced obsessivecompulsive and related disorder Obsessive compulsive and related disorder due to another medical condition 45 46 DSM IV diagnosis of trichotillomania DSM 5 trichotillomania (hair pulling disorder) DSM IV classification impulse control disorders not elsewhere classified DSM 5 obsessive compulsive and related disorders It is acceptable to diagnose a patient with a panic disorder with or without agoraphobia. True False ** 47 48 Cadena 8
FALSE 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. 49 50 DSM 5 criteria for posttraumatic stress disorder (PTSD) differ significantly from those in DSM IV. DSM IV three major symptom clusters re experiencing, avoidance/numbing, and arousal DSM 5 4symptomclusters 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 selfdestructive behavior ** 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 51 52 TRUE DSM-5, somatoform disorders now referred to as somatic symptom and related disorders. Diagnoses removed- somatization disorder hypochondriasis pain disorder undifferentiated somatoform disorder 53 54 Cadena 9
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 in emotional and behavioral self control. Gambling Disorder DSM 5 not separate diagnoses of substance abuse and dependence as in DSM IV. DSM 5 substance use disordercriteriaare nearly identical to the DSM IV substance abuse and dependence criteria combined into a single list, with two exceptions. 55 56 DSM IV recurrent legal problems criterion for substance abuse has been deleted from DSM 5 DSM 5 (new)cravingor a strong desire or urge to use asubstance. DSM 5 (new) Cannabis withdrawal Caffeine withdrawal 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 are subsumed under newly named entity DSM 5 less severe level of cognitive impairment, mild NCD ** 57 58 The diagnosis of mild neurocognitive disorder should include a subtype specify whether due to: TRUE True False 59 60 Cadena 10
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. Section III Emerging Measures and Models 61 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. Assessment Measures Cultural Formulation Alternative Model for Personality Disorders Conditions for Further Study 63 64 Cross Cutting Symptom Measures Self Rated DSM 5 Level 1 Cross Cutting Symptom Measure Adult Parent/Guardian Rated DSM 5Level1Cross Cutting Symptom Measure Child Age 6 17 Clinician Rated Dimensions of Psychosis Symptom Severity 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. 65 66 Cadena 11
Culture systems of knowledge, concepts, rules and practices that are learned and transmitted across generations. Characterized by impairments in personality functioning pathological personality traits Cultural Formulation Interview (CFI) 16 questions impact of culture on key aspects of clinical presentation & care Cultural Formulation Interview (CFI) Informant Version Glossary of Cultural Concepts of Distress 67 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 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 69 70 CPT CURRENT PROCEDURAL TERMINOLOGY 71 72 Cadena 12
Diagnostic Psychotherapy Psychotherapy with E/M Other Psychotherapy Other Psychiatric Services Service Diagnostic interview examination Interactive diagnostic interview examination CPT Code 2013 Change 90801 DELETED 90802 DELETED 73 74 Diagnostic evaluation (no medical) Diagnostic evaluation with medical Diagnostic evaluation (no medical) Diagnostic evaluation with medical 90791 WHEN APPROPRIATE 90792 WHEN APPROPRIATE 90791 YES 90792 YES Service CPT Code 2013 Change Individual psychotherapy 20-30 minutes 90804, 90816 45-50 minutes 90806, 90818 DELETED 75-80 minutes 90808, 90821 Interactive individual psychotherapy 20-30 90810, 90823 DELETED minutes 45-50 minutes 90812, 90826 75-80 minutes 90814, 90828 75 76 Service Psychotherapy 30 minutes (16 to 37 minutes) 45 minutes (38 to 52 minutes) CPT Code Change 90832 Report with Interactive complexity (+90785) 90834 When appropriate Service Interactive Psychotherapy 30 minutes (16 to 37 minutes) 45 minutes (38 to 52 minutes) CPT Code Change 90832 Yes 90834 Yes Report with Interactive complexity (+90785) 60 minutes (53+ minutes) 90837 60 minutes (53+ minutes) 90837 Yes 77 78 Cadena 13
Service CPT Code 2013 Change Individual psychotherapy with E/M 20-30 minutes 90805, 90817 45-50 minutes 90807, 90819 DELETED Service Code Report with interactive complexity (+90785) 75-80 minutes 90809, 90822 Interactive individual psychotherapy 20-30 minutes 45-50 minutes 90813, 90827 90811, 90824 DELETED E/M + psychotherapy Add on E/M code selected (key components not time) and 1 of: + 90833 (30 mins) +90836 (45 mins) +90838 (60 mins) When appropriate Yes 75-80 minutes 90815, 90829 79 80 Service CPT Code 2013 Change Service CPT Code Report with interactive complexity (+90785) Family psychotherapy Group psychotherapy 90846, 90847, 90849 RETAINED 90853 RETAINED Psychotherapy for crisis 90839, + 90840 Family psychotherapy 90846, 90847, 90849 Group psychotherapy 90853 NO NO When appropriate Interactive group 90857 DELETED Interactive group psychotherapy 90853 Yes psychotherapy 81 82 Service Code 2013 Change Service Code Report with interactive complexity (+90785) Pharmacologic 90862 management 90863 DELETED Prescribing psychologists only Evaluation and management E/M code No 83 84 Cadena 14
E/M E/M Alone E/M PLUS Psychotherapy 85 Outpatient: 99204,05,12,13,14,15 Inpatient: 99222,23,31,32,33 86 Psychotherapy 30 (16-37*) minutes E/M Code and 90833 Psychoanalysis Family Therapy Psychotherapy 45 (38-52*) minutes E/M Code and 90836 90845 Pt present, not present,group Time: 30,45, 60 minutes 60 (53+*) minutes E/M Code and 90838 87 88 Start with a 99 Used to document what happens in a patient encounterrendering a medical service Evaluation (collecting and assessing information) and Management (planning treatment or further assessment; prescribing medication) Used by all other medical providers 89 90 Cadena 15
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 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 91 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 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 93 94 Category of Problems/Major New symptoms Points per problem Self-limiting or minor (stable, improved, or worsening) 1 (max=2) Established problem (to examining physician); stable or 1 improved Established problem (to examining physician); worsening 2 New problem (to examining physician); no additional 3 workup or diagnostic procedures ordered (max=1) New problem (to examining physician); additional workup 4 *Additional workup does not include referring patient to another physician for future care planned* Level Total Data Points Minimal 0-1 Limited 2 Multiple 3 Extensive 4 95 96 Cadena 16
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 Points each) 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 1 someone other than patient Review and summarization of old records and/or obtaining 2 history from someone other than patient and/or discussion of case with another health care provider Independent visualization of image, tracing, or specimen itself 2 (not simply review report) 98 Level Total Data Points Minimal or none 0-1 Limited 2 Multiple 3 Extensive 4 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 99 100 Level of Risk * Presenting Problems Diagnostic Procedure Management Options Selected Level of Risk Minimal Risk Low Risk Presenting Problems One self-limited or minor problem, e.g., dysthymia well-managed Two or more self-limited or minor problems; One stable chronic illness; Acute uncomplicated illness Diagnostic Procedure Laboratory tests Chest X-rays EKG/EEG Urinalysis Physiologic tests not under stress, e.g., PFTs Glucose monitoring Management Options Selected Rest Stay home from school OTC drugs 101 Mod Risk High 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 One or more chronic illnesses with severe exacerbation, progression, or side effects; Acute or chronic illnesses that pose a threat to life or bodily function None that would be done in out-patient psychiatry! None that would be done in out-patient psychiatry! Prescription drug management Drug therapy requiring intensive monitoring for toxicity (clozapine) 102 Cadena 17
# Diagnoses or Management Options Minimal [0-1 problem points Limited [2 problem points] Multiple [3 problem points] High complexity [4 problem points] Amount and/or Complexity of Data to be Reviewed Minimal or none [0-1 data points] Limited [2 data points] Multiple [3 data points] Risk of Complications and/or morbidity/ mortality Minimal Low Moderate Requires 2 out of 3 areas in the outpatient office setting Extensive Extensive [4 data points] DESIGNATED LEVEL OF MEDICAL DECISION-MAKING STRAIGHTFORWARD 99202-99212 LOW COMPLEXITY 99203-99213 MOD COMPLEXITY 99204-99214 HIGH COMPLEXITY 99205-99215 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 History of Present Illness Review of Systems Past, Family, Social History (CC) (HPI) (ROS) (PFSH) Document in patient s own words My moods make me feel like I m always in a storm. 105 106 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 The patient reports continual 1 emotional 2 problems of moderate 3 anxiety 4 starting with the Failure from college 5 two weeks ago 6, now does not want to live in the same house with parents 7 and associated with disrupted sleep, loss of appetite & suicidal thoughts 8. 1. Location 2. Quality 3. Severity 4. Duration 5. Timing 6. Context 7. Modifying Factors 8. Associated signs/symptoms 107 108 Cadena 18
Brief Levels of History of Present Illness Extended 1. Location 2. Quality 3. Severity 4. Duration 1-3 elements OR Status of 1-2 chronic or inactive conditions 4 or more elements OR Status of 3 or more chronic or inactive conditions 5. Timing 6. Context 7. Modifying Factors 8. 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 Pertinent Complete Levels of PFSH 1 item from 1 of 3 areas New Patient: 3 out of 3 areas Established Patient: 2/3 areas 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 111 112 Problem pertinent: Extended: Complete: Review of Systems Requirements System directly related to the problem(s) identified in the HPI 2 9 systems 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 Brief: 1-3 elements or 1-2 chronic conditions Extended: 1-3 elements or 1-2 chronic conditions Extended: 4 elements or 3 N/A N/A Problem-focused 99202/99212 N/A Pertinent 1 element* Problem Pertinent 1 Extended 2-9 systems Expanded problem-focused 99203/99213 Detailed 99204/99214 Complete 3 Complete 10-14 Comprehensive 99205/99215 chronic conditions elements** systems *No PFSH required with subsequent hospital visits **2 elements for established patients 114 Cadena 19
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 115 116 Comprised of the following systems Constitutional Musculoskeletal Psychiatric 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 117 118 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 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) 119 120 Cadena 20
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) Elements of Examination Level 1-5 elements Problem-focused 99202, 99212 At least 6 elements Expanded problemfocused 99202, 99213 At least 9 elements Detailed 99203, 99214 Perform all elements Comprehensive 99204, 99215 121 122 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 MEDICAL COMPLEXITY DECISION MAKING SF SF LOW MODERATE HIGH Comprehensi ve 123 124 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, Temperature: abnormal movements (e.g. flaccid, cog wheel) Respiration: Height: Note: Weight: General appearance of patient (e.g. development, nutrition, body habits, deformities, Well Groomed Disheveled Bizarre Inappropriate Note: 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 125 126 Cadena 21
October 7th revisionshttp://www.dsm5.org/documents/important%20co DING%20CORRECTIONS%20FOR%20DSM- 5%2010-7-13.pdf Assessment measures (online) http://www.psychiatry.org/practice/dsm/dsm5/onlineassessment-measures Thank you!!! DrSJCadena@gmail.com 127 128 Cadena 22