Over the weekend I made up a form that may help. (You can skip to the end for the links to download it if you want to cut to the chase.)
The form can be printed out and filled in, either during a session, or afterwards; alternatively, it can be used for reference, to learn the coding system. It captures—I think—all of the bits of documentation mentioned in the E/M documentation standards for psychiatry. I tried to make it so that the various pieces are grouped together logically, with reasonably good design. It contains the standards and criteria for all the psychiatry E/M codes that I'm aware of: inpatient, outpatient, initial, subsequent, and all the levels. (The reference sheet that I did that is available here only does levels 2-4, and only the outpatient follow-up codes; but it does include the psychotherapy codes and add-ons, and the simpler non-E/M evaluation codes, which this one doesn't.)
The form is not
- something that contains all the elements of a complete medical record note; like the E/M documentation standards, it omits a number of very basic things like, uh, a medication list, a plan, etc. I may do a second page at some point.
- a guide to how you should conduct an interview
- something that can be filled out on line, though it would be possible to turn it into an electronic form, and I may do that at some point
- any kind of endorsement by me of this whole scheme of coding, billing, and documentation, although—even though I am someone who does not take care of the most complex medication patients—I am sympathetic with the idea that people who do should get paid more
Some ways you might use it:
- I originally thought of printing this form two-sided. It should work well for that, but when I realized that the note will need more than is on the form, I thought I might print it on two pages and use the back for additional notes. It should work fine for this as well because the name is repeated at the top of the second page.
- Rather than using it in the session, you could sit down after a session and see where all the data you gathered fits on it, and then use it to see where you are in terms of coding.
- It can be used as a way to understand the coding system.
Also as mentioned on the other page: this is a good faith reflction of my understanding as of the moment of the writing. I am making no representation that it is entirely correct or problem-free, and the responsibility for your coding or documentation rests, as it always has, with you. But I hope this helps.
So here are the links:
- I will try to keep this a link to the current pdf
- I will try to keep this a link to the current Word .doc file
- This is a link to the original pdf of 1/6/13
- This is a link to the original Word .doc of 1/6/13
- The link tiny.cc/emform can be distributed to anyone who's interested; it points back to this blog entry, and I plan to keep it pointing either here or to some other explanatory page
- The link tiny.cc/natpsych points to this blog as a whole
Good luck! Feedback welcome, as long as you're not blaming me for this whole imbroglio.
Psychiatry E/M Encounter Form by Nat Kuhn, MD is licensed under a Creative Commons Attribution 3.0 Unported License.