Comprehensive examination

Any advice performing/documenting comprehensive psychiatric examination (for example for 99204 or 99205)
Specifically refer to documenting 3/7 vital signs. Any thoughts about recording/examining pulse or blood pressure.
Also muscle strength and tone.

We are asking patients who have BP cuff, pulse ox, scale at home to have those numbers ready for the call and we can input that data. it is definitely hard to get a 99204 without being able to examine the patients. At this point, I’m feeling at least a 99213 is better than nothing. Gotta stay afloat.

Contrary to popular belief, billing level is more closely related to complexity of visit and/or time spent with patient than the number of ROS or PE items listed. Make sure you document medical decision making and time spent as well as patient complexity regarding medications if you want to bill at the 99214-5 or 99204-5 levels