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Coding for Distraught Psychiatric Patients


Can you code when a patient is so distraught an appropriate history cannot be obtained, nor can a mental status exam be performed?

Distraught Psych Patients

Q: I'm a psychiatrist and am often called upon to admit patients that are so distraught that not only can an appropriate history not be obtained, but a good mental status exam cannot be performed. I know there is an exception for history unobtainable, but what about the exam? These are difficult patients but I don't meet admit code criteria.

A: Good points regarding the history and exam for these type patients. With the 'history unobtainable' or partly unobtainable you are good there, but there is no such 'disclaimer' for the exam. Do remember that the Federal documentation guidelines state that they are for the 'typical adult population' and that some variance is allowed.  However, this approach often does not find favor with payers.

Have you considered coding by time counseling? Many psych services resemble counseling anyway. Look into this.

Or alternatively, have you considered the use of CPT code 90839 – psychotherapy for crisis? It actually pays better than some admit codes – about the same as the 99222. That is, of course, if you are doing at least 30 minutes' worth of psychotherapy. That may not be possible in the situation you describe. Or, could what you are doing be described as 90792 Psychiatric Diagnostic evaluation? These do not have the more rigid documentation criteria of the admit codes.

One of these options may well be a better fit than trying to shoehorn your work into the standard admit code. Give those codes and requirements a look in the CPT manual.


92214 Coding Specifics
We see some of our providers documenting 'greater than 30 minutes spent with the patient and over half of that spent counseling' and then billing the 99214. But when we look at the content, it is one stable chronic and mostly tobacco cessation counseling. Can we do this?

A: Good observation but this one may not break in the favor of your provider. Certainly spending most of a 30-minute visit counseling codes can be billed 99214, but there are some other rules in operation as well.

If the bulk of the counseling time was spent in tobacco cessation counseling, then there is a more specific code for that, 99406 or 99407, depending on the amount of time spent.

Rather than using a general coding convention such as time, if there is a more specific code that describes the service, CPT would suggest that you use that. In this case, if over half of the thirty minutes was counseling, that's at least 16 minutes, and ten of that was tobacco cessation (99407), then what you really have left is a 20-minute visit with six minutes of counseling - more of a 99213. If three minutes were spent on tobacco cessation (99406) then you have a 27 minute visit with 13 spent counseling – again closer to a 99213 and a 99406.

The 99214 does pay more than either of these combinations, but you run the risk of having someone parse it this way. It pretty much work the same for two stable chronic diseases and tobacco cessation. Watch your language carefully in the A/P when tobacco cessation is involved.


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