Psychiatry Jeffrey Cook Question & Answer Guide (With Explanation)
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Original Question
Psychiatry Re: Jeffrey P. Cook MR # 700-1 Date of Service: January 5, 20XX Past psych history: 1x past psychiatric admission in 8/20XX, past psychiatric medications – Celexa, no drug rehab. Has been in AA. Hypertension Digestive Problems Depression Anxiety Tobacco Use Smoking Status: current smoker Patient is: Thinking about quitting Usage per day: 0.5 packs Type: cigarettes Smoking cessation packet: previously given Age started: 20 How often does the patient smoke: every day Patient is a: moderate tobacco smoker (10-19 cigarettes per day) | Psychiatric: Suicidal thoughts -Pt admits to suicidal ideation, but no plan and does not believe he is a danger to himself at the moment. He has been requested to go to St. Mary’s should he feel like hurting himself. Other concerns- none. Session Note – Follow-up Exam: Patient’s Report – This patient was present and on time for this appointment. States “Not too good”. Today patient is distraught, sad, tearful, staring into space, complains of memory lapse, forgetfulness even losing his way on his journey down here today. Patient gives himself a 2 on a scale of 10 for wellbeing. That is the most distressed that I have seen him. He continues to hear voices that he Behavioral Observaton- Mental Status is alert, engaged, alkalve, but sad and pensive. Intervention Used- CBT, Solution-Focuses, Supportive. Focus of Session- Pt volunteers that his job has terminated so he believes he has lost his insurance. I suggested that if he has to choose his treatment modalities based on the cost factor, the one relationship he cannot jeopardize is that with Dr. G since medications are essential for him to be able to function. He complains that he and his wite are struggling because he does not feel well enough to engage with her and the family. He states, “I keep apologizing but I just can’t function in any relationship”. He takes his medication when he remembers; He has forgotten on occasion. He had a Social Security hearing but not all data was available. We are inquiring about sending Dr. G’ s records. Dr. C’ s and mine have been sent. His case will be continued for 3 more months. When l asked about his children, he cried pretty intently and the source of his tears is the remorse that he foels because he is not fulfilling his role as a father as he believes he should. They are financially surviving. They are working on credit rating to acquire a better home. When asked about a miracle he would like to see occur in his home, his wish was that his health be restored so that he could contribute to the family as he believes he ought. He wants life to get back to normal.6 Assessment of Progress: Patient Response- Pt. is distraught and sad today and doesn’t feel well. Plan Continue counseling End Time: 12:01 PM 1. Schizoattective disorder. unsnocitedl Suicidal ideations Depression Rule out dependency personality traits. Chmical Notes: Continue counseling blectronically signed by kev Looper, LC on 01/05/ 20XX â‚«1 1424 Psychiatry Cocing Fee licket Patient Name Medical Record Number/Account Number Provider Insurance Company Comments effrey P. Cook 700-1 Kevin Cooper, L.PC United Behavioral Health The documentation supports what CPT* code(s)? A. 90791 B. 90832 C. 90832, 90785 D. 90837 What discrepancies have been identified? The procedure code is reported incorrectly and billed under the wrong provider. The diagnosis code is reported incorrectly. The procedure and diagnosis codes are reported incorrectly. The procedure code and diagnosis code are reported incorrectly and billed under the wrong provider.
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