Name of the Procedure:

Mental Health Assessment, by Non-Physician Common names: Mental health evaluation, psychological assessment, psychiatric screening Technical/medical term: HCPCS code H0031

Summary

A mental health assessment conducted by a non-physician healthcare provider aims to evaluate an individual's psychological and emotional well-being. It involves a series of interviews, questionnaires, and possibly observational techniques to diagnose mental health conditions and develop an appropriate treatment plan.

Purpose

• Conditions/Problems: Depression, anxiety, bipolar disorder, PTSD, schizophrenia, and other mental health issues.
• Goals/Outcomes: Diagnose mental health conditions, understand the severity, and formulate a treatment plan that may include therapy, medication, or referrals.

Indications

• Symptoms: Persistent sadness, excessive worry, mood swings, trauma, hallucinations, and other emotional or psychological distress.
• Patient Criteria: Individuals experiencing mental health symptoms, those who have been referred by a physician or another healthcare provider, or those undergoing routine mental health check-ups.

Preparation

• Pre-procedure Instructions: No specific preparations required. Patients should bring a list of current medications, past mental health history, and any previous assessment results if available.
• Diagnostic Tests: Not typically required beforehand, but having prior assessments can be beneficial.

Procedure Description

1. Initial Interview: The non-physician healthcare provider will conduct a structured or semi-structured interview to gather information on medical history, present symptoms, and psychosocial issues.
2. Questionnaires: Standardized mental health questionnaires may be administered to quantify symptoms and aid in diagnostic accuracy.
3. Observation: Behavioral and emotional observations during the interview.
4. Feedback: The provider discusses initial findings and possible next steps with the patient.

Tools

• Standardized questionnaires (e.g., PHQ-9, GAD-7)
• Diagnostic interview protocols

Anesthesia/Sedation

• Not applicable.

Duration

• Typically takes about 60 to 90 minutes.

Setting

• Outpatient clinic, community health center, mental health facility, or private practice.

Personnel

• Licensed clinical social workers (LCSWs), licensed professional counselors (LPCs), clinical psychologists, or other trained and licensed non-physician mental health professionals.

Risks and Complications

• Common Risks: Emotional distress triggered by discussing sensitive issues.
• Rare Risks: Misdiagnosis due to incomplete information.
• Management: Immediate support and referrals to additional services if distress occurs.

Benefits

• Expected Benefits: Accurate diagnosis and tailored treatment plan.
• Timeline: Benefits such as improved mental health may be noticed within weeks to months, depending on the treatment plan.

Recovery

• Post-Procedure Care: Follow-up appointments for therapy or consultations.
• Recovery Time: No physical recovery time needed, but ongoing mental health follow-up is usually required.
• Restrictions: None, but patients are encouraged to engage in recommended treatments and follow up as scheduled.

Alternatives

• Other Options: Assessment by a psychiatrist or general practitioner, self-assessment tools, support from peer networks.
• Pros and Cons: A psychiatrist may provide medication and more comprehensive medical evaluation, but scheduling may be more challenging. Self-assessment tools are accessible but less reliable.

Patient Experience

• During the Procedure: Patients might feel a range of emotions, from relief to distress, as sensitive topics are discussed.
• After the Procedure: Patients should feel a sense of direction and a plan for managing their mental health. Emotional support and pain management strategies, such as mindfulness and counseling, may be provided.