ACBHCS QA 4.2013 - Alameda County Behavioral Health

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Path 1: Choosing the E/M Code Based on Time: Counseling & Coordination of Care AUDITOR’S WORKSHEET Yes No Does documentation reveal total time (Face‐to‐face in outpatient setting; unit/floor in inpatient setting) and indicate > 50% of the total time was counseling and coordination of care services? Does documentation describe the content of counseling or coordinating care? Does documentation support that more than half of the total time was counseling or coordinating of care? Note. If all answers are yes, select level based on time.
Path 2: Choosing the E/M Code Based on the Elements • History • Exam • Medical Decision Making ‐ Chief Complaint ‐ History of Present Illness (HPI) ‐ Past, Family and/or Social History (PFSH) ‐ Review of Systems (ROS) ‐ Number of system/body areas examined ‐ “Bullets” or elements completed within specific systems ‐ Number of Diagnoses or Management Options ‐ Amount and/or Complexity of Data to be Reviewed ‐ Risk of Significant Complications, Morbidity, and/or Mortality Each line impacts kind of History, Exam, and MDM
Page 1 and 2:
ACBHCS QA 4.2013
Page 3 and 4: AGENDA • Why we are doing this tr
Page 5 and 6: New InSyst Procedure codes map to M
Page 7 and 8: Retained Procedure Codes Old New CP
Page 9 and 10: Psychiatric Diagnostic Evaluation P
Page 11 and 12: Non E/M Codes (Psychotherapy & Cris
Page 13 and 14: Time Spent in Session: examples 1.
Page 15 and 16: PSYCHOTHERAPY FACE TO FACE TIME = 3
Page 17 and 18: Add‐On Codes (+) Add‐On (+) cod
Page 19 and 20: Crisis Code 377‐90839 (Used Alone
Page 21 and 22: Crisis Code 377‐90839 + 378‐908
Page 23 and 24: Add‐On Code for Additional Servic
Page 29 and 30: Interactive Complexity (+) 491‐ 9
Page 31 and 32: Psychotherapy Add‐on Codes to E/M
Page 33 and 34: Evaluation and Management (E/M) Cod
Page 35 and 36: CPT E/M New client Definition—CBO
Page 37 and 38: Two Paths to E/M Selection • PATH
Page 39 and 40: Path 1: Choosing the E/M Code Based
Page 47 and 48: See hand‐outs Progress Note Templ
Page 49 and 50: Medical Necessity—CMS • The Cen
Page 51 and 52: General Principles of Documentation
Page 53: Path 1: Choosing the E/M Code Based
Page 57: Path 2: Choosing the E/M Code Based
Page 63 and 64: See E/M Progress Note Template Base
Page 65 and 66: Medication Support: RN/LVN/Psych Te
Page 67 and 68: Elimination of AB3632 procedure cod
Page 69 and 70: Training Resources: The National Co
Page 71: Resources continued: • AMA Code B
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ACBHCS QA 4.2013 - Alameda County Behavioral Health

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