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Diagnosis question

Silvia Posted Wed 08th of July, 2020 10:58:19 AM
Visit was billed with G47.00 payer denied, the note under assessment also has depression and anxiety. Two questions can i bill for depression and anxiety also, and can i sequence the depression and anxiety first and G47.00 last? 3/23/2020 UCI BIRCH PSY AND HUMAN BEH Neikrug, Ariel B Psychology Insomnia, unspecified type Dx Insomnia ; Referred by Self, Referred Reason for Visit Progress Notes Due to COVID-19 pandemic and a federally declared state of public health emergency, this service is being conducted via telephone. Consent was obtained from the patient. Pt is currently in CA.   Therapy Note   Subjective:  Brent Martens is a 52 year old male came for follow up session for insomnia disorder. He partially completed his sleep log on sleepio. Reported a challenge to get into bed by 11:30. He reported that because he fight sleeping he wakes up and the is not ready to get to sleep on the correct time.   Objective: Brent Martens came to the session on time. Physical appearance: appropriate appearance   , adequate grooming    and well-nourished    Relatedness: engaged Eye contact: good  Attitude: cooperative Speech quality: clear with normal rate and volume    Motor behavior: normal Mood: euthymic Affect: congruent Thought process: linear, organized Thought content: no evidence of psychotic symptoms Suicidal ideation: none Homicidal ideation: none Orientated to: x3 Sensorium: intact Attention/Concentration: grossly intact   Memory: grossly intact  Insight: intact Judgment: intact   Assessment: Brent Martens is a 51 year old male who presents with suspected Insomnia.  Patient reported symptoms that are consistent with a possible diagnosis of OSA. However, a recent HAST indicated an AHI=1.4.  He reported multiple awakenings during the night. Patient also reported symptoms consistent with insomnia disorder. He reported a behavioral pattern that may be exacerbating sleep dysfunction. These behaviors tend to include increasing bedtime, changing bed times, changing meds, napping, and chasing sleep. Patient also reported symptoms of depression and anxiety. He may benefit from a group approach (he agreed and is on the wait list for this group). Based on this assessment the following is recommended:    Interventions applied: CBT-I    Sleep Window: 11:30pm to 6:30AM   Plan:   1) discontinue all naps.   2) Session #2 sleepio 3) continue maintaining sleep log. Make sure that all data is transferring.   4) join the Monday group (mood) 5) Join the group. 6) in the first 2 hours of the day, spend a minimum of 30 minutes outdoors without sunglasses. (new rec). Patient agreed with this plan: yes   Time spent direct face to face with patient: 42 min.   Additional Documentation Encounter Info:   Billing Info, History, Allergies, Detailed Report Media Scan on 3/24/2020 1429 by Leon, Polo: EMAIL (USE OF) Orders Placed None Medication Changes None Medication List Visit Diagnoses Insomnia, unspecified type G47.00 Problem List
SuperCoder Answered Thu 09th of July, 2020 04:01:06 AM
Hi Silvia AAE does not provide coding reviewing for operative reports and chart notes SuperCoder offers SuperCoding on Demand SOD http www supercoder com coding-answers coding-on-demand for coding reviewing of an operative report or chart note and you can contact - or e-mail customerservice supercoder com for more information Hope...

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