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Psychiatry Re: Carla D. Hall Date of Service: January 26. 20XX roke ack denciency Thyroid disease Psychiatric: Suicial thoughts no. Other concerns none. session Note • rollow Up Exam: Patient’ s Report: Patient and husband were present and on time for this appointment. She complained of being tired and her eyes hurting. Behavioral Observation/Mental Status: Depressed, flat affect, very poor eye contact; probably histrionic, guarded; negative for suicidal/homicidal ideation; judgment fair and insight partial. Intervention Used: Supportive. Focus Of Session: Patient was guarded and not volunteering information to the counselor. She did answer questions. She has been oing her art, some journaling, some exercise. Her eyes are hurting and there may be an issue with a psychotropic medication. ” Ion t want to change medicine. She was encouraged to do what is best for her despite how she mient teel about it. She really was no engaged in the counseling session and said after she first sat down that she wanted to go home. Supportive counseling. Assessment of Progress/Patient Response: Guarded. Patient will engage in her counselling session next visit. Suicidal thoughts will be eliminated 100% one day at a time. Will revisit progress and address any new developments next session. Plan: Continue counseling. See in 1 week. Start Time: 04:00 PM End Time: 04:40 PM 1. Depressed Problems related to the social environment GAFS1. Clinical Notes: Individual Therapy. Patient Name Medical Record Number/Account Number Provider Insurance Company Comments Date of Service Facility Physician Group Total Place of Service 11 Psychiatry Coding Fee Ticket Carla D. Hall 700-6 Kevin Cooper, LPC United Behavioral Health CPT• Code(s) Diagnosis Code(s) 90834 F32.A Modifier Quantity Fee $200.00 $200.00 1. The documentation supports what CPT® code?

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