Behavioral Health Peer Review Form

Follow-Up Visits(90832, 90834, 90837, 90847)

Clinician’s Name: ______Pt # ______

Reviewer’s Name: ______

Date of Review: ______Year/Quarter: ______

Follow-Up Visits / YES / NO / N/A
Chief Complaint:
  • Reason for appointment?

  • Start & stop times

  • Other people in attendance? Indicate if family session.

HPI:
  • Pt symptoms & concerns; statement regarding pt’s functioning

Examination (Therapeutic Interventions):
  • Observations

  • Focus of Session

  • Progress toward tx goals

  • Pt response/receptiveness to interventions

  • If family session, note indicates focus of tx is on pt’s condition

Assessment:
  • Diagnosis(es)

  • Tx goals for each Dx or changes in tx plan (if any) and rationale for changes

Treatment:
  • Diagnosis(es)

  • Focus of session & clinical interventions

Procedure Code: (90832, 90834, 90837, 90847)
  • Does it coincide with start/stop times?

MISC:
  • Follow-up documented?

  • Is note billed?

  • Is note locked?

Comments:

Behavioral Health Peer Review Form

Intake Visit (90791)

Clinician’s Name: ______

Reviewer’s Name: ______

Date of Review: ______Year/Quarter: ______

Intake Visit – Pt. #1 / YES / NO
Chief Complaint:
  • Referral source (PCP, self, etc.)

  • Reason for referral

  • Start & stop times

  • Other people in attendance listed

HPI:
  • Presenting Problem:

  • Description of concerns and sxs

  • Onset and duration of sxs

  • Symptom list

  • Precipitating factors

  • Patient Psychiatric Hx

  • Family Psychiatric Hx

  • Psychotropic Medication (Current & Past)

  • Medical Illnesses (Current & Past)

  • Abuse Hx (Emotional, Physical, & Sexual)

  • Substance Use/Abuse (Current, Past, & Family)

  • Psychosocial Assessment:

  • Developmental Hx & Family of Origin

  • Support System/Current Living Situation

  • Employment & Level of Education

  • Financial Status

  • Legal Status

Examination:
  • Diagnosis(es) – All 5 Axes

  • MSE

  • Clinical formulation – summary & rationale for Dx, factors contributing/relevant to Dx and Tx plan

  • Strengths

Assessment:
  • Diagnosis(es) – listed, accurate, & supported by documentation?

  • Treatment goals for each Dx

  • Estimated duration of treatment

Treatment/Plan:
  • Diagnosis(es)

  • Interventions, instructions, etc. given to pt

  • Pt’s ability and level of motivation to work on goals

Procedure Code: (90791)
  • Correct code for intake?

MISC:
  • Follow-up documented?

  • Is note billed?

  • Is note locked?

Comments: