Code Crunchers
This code is used for an integrated biopsychosocial assessment or an initial evaluation
What is 90791 or H0031?
Notes must be locked/signed within this time frame.
What is 24-48 hours?
This is the correct method to make a correction to a clinical record when documenting electronically
What is adding an addendum?
This is one of two assessments completed by the client at intake
What is the WHODAS or the DSM-5-TR Cross-Cutting Measure?
This code is used for 53min+ of psychotherapy.
What is 90837?
Diagnoses from this text are used for Medicaid clients
What is the DSM?
If a clinician makes a correction to a clinical document, they must provide this information to maintain the integrity of the record
What are the date and reason for the amendment?
This is what you ask a client to elicit their standard routine.
What is a typical day for you?
This code is used for a low complexity OT evaluation and is intended to last this long
What is 97165 for 30 minutes?
If completing a home visit, you would generally want to park here
What is in a visitor/public parking spot?
According to Medicare guidelines, failing to appropriately amend clinical documentation could lead to these consequences.
What are claim denials or fraud allegations?
This type of screening elicits observable results
What is an objective screening?
These are generally the first two numbers of medical codes used in occupational therapy.
What are “97”?
If a client cancels their appointment less than 24 hours in advance, it is marked as this.
What is a late cancellation?
When making a late entry in clinical documentation, it must clearly state this to avoid confusion.
What is the fact that it is a late entry and the reason for the delay?
This cognitive strategy involves breaking tasks down into smaller, more manageable steps
What is task analysis?
These are generally the first two numbers of behavioral health codes for Medicaid.
What are “90”?
This must be completed for every client at least every 90 days or sooner if their condition changes.
What is the treatment plan update?
This is the term used for deliberately falsifying or altering a clinical document after a claim has been submitted to Medicare.
What is record tampering?
This type of intervention helps clients modify their environment to support daily routines
What is environmental adaptation?