Psychiatry Ryan Andrews Question & Answer Guide (With Explanation)
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This question relates to psychiatry ryan andrews and requires a structured academic response.
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Original Question
Psychiatry Re: Ryan P. Andrews MR # 700-1 Date of Service: January 7, 20XX Tobacco Use: Smoking Status: former smoker How long has it been since the patient last smoked? 1-3 months Type: cigarettes Smokeless Tobacco Current user: Yes Usage per day: less than 1 can or pouch Age started: 15 Patient is: ready to quit Drugs/Alcohol: Drugs Use. None Type: N/A Time since patient last used: N/A Alcohol Screen Did you have a drink containing alcohol in the past year? Yes How often did you have 6 or more drinks on one occasion in the past year? Four or more times a week (4 points) How many drinks did you have on a typical day when you were drinking in the past year? S or 6 drinks (2 points) How often did you have a drink containing alcohol in the past year? Weekly (3 points) Interpretation Positive Psychiatric: Suicidal thoughts no. Other concerns none. Session Note – Follow-up Exam Patient’ s Report This patient was present and on time for this appointment., “Pretty good” Pt. gives himself a 7/8 on the 10 scale. Pt. Says, “T’ m doing good and living life.” Patient spends his weekends enjoying his friends and family. Spent the last weekend on the river and this weekend going with his favorite cousin to south MO to visit his uncle. Overall pt. says he feels better about himself and is taking time now to focus on doing what he enjoys and making himself happy rather than worrying about what others think and want. Behavioral Observation/Mental Status: Alert, engaged, talkative, focused Intervention Used: CBT, Solution-Focused, Supportive. Focus of Session: A major issue for patient has been his use and abuse of alcohol which he has used excessively as he has tried to deal with the sudden death of his wife three years ago on June 3ª. He indicates he has continued to use alcohol but had reduced his consumption. He has been warned that his addictive tendencies make control drinking an impossibility in most cases. Spent Easter with his family. He is more open today about dealing with the death of his wife. He still has not discarded some of her things although he did sell her Jeep at the beginning of this year. His wife’s grandpa died a month ago and being with her family brought a lot of things back. He has not been dating anyone in particular. ‘T m just trying to be now.” Assessment of Progress/Patient Response Mood and affect are stable. Plan Continue counseling, Start Time 8:02 AM 1. Alcohol dependence 2. Mair depression in naria remission Clinical Notes: Continue Counseling Electronically signed by Kevin Cooper, LPC on 01/07/20XX at 1300 Psychiatry Coding Fee Ticket Patient Name Medical Record Number/Account Number Provider Insurance Company Comments Ryan P. Andrews 700-1 Kevin Cooper, LPC United Behavioral Health Total $200.00 The documentation supports what CPT* code(s)? A. 90791 B. 90832 C. 90832, 90785 D. 90837 What discrepancy has been identified? The ICD-10 CM code F10.10 is for alcohol abuse and it should be for alcohol dependence F10.20. A code for drug dependence should also be reported. The CPT” code is not correct. No discrepancies, the CPT * and diagnoses codes are reported correctly.
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