Health record of a female patient who received psychiatrist treatment services in a hospital outpatient-based clinic.

The following documentation is from the health record of a female patient who received psychiatrist treatment services in a hospital outpatient-based clinic. XX/XX/XX 6:20 p.m. Dialectical behavior therapy (DBT), individual therapy-1:1 for 45 minutes at 5 p.m. Subjective/Objective: Patient and I reviewed diary card, targeting hospitalizable behaviors and increasing skills to stay out of the hospital and complete the outpatient program. Target goals 1 through 3 were reviewed today. Patient did not engage or act on urges for self-harm and urges for suicide after self-injurious behavior on XXXX/ XX. We focused on reinforcing skills of emotion regulation, highlighting times she used these while at work and with family members. Suicidal ideation today was minimal. with sense of increased willingness to learn to apply skills. Discussed need to address: ETOH dependence because patient notes increased risk of suicidal ideation with ETOH use. She identifies "fear" of "running in panic" will be what keeps her from staying with chemical dependency (CD) program. We addressed treatment plan (see below) to increase skills associated with CD treatment follow-through as well as structuring environment to "keep me in CD treatment. Assessment: Moderate major depressive disorder, recurrent; chronic posttraumatic, stress disorder, ETOH dependent; borderline personality disorder. Continued suicidal risk; patient has had some success over urges but is now coping well with the outpatient treatment where she receives therapy four times a week. Plan: Patient and I identified targeting emotion regulation and distress tolerance!? in individual therapy to increase control over urges for suicidal thoughts, as well as follow-through with substance abuse treatment. Extended structuring continues with? increased resources for managing son’s behavior at home. Patient wants family meeting to orient family to DBT to increase chance they will be supportive of her treatment after discharge as opposed to disparaging, which, according to the patient, has increased her emotional vulnerability leading to increased suicidal urges. I gave times I would be available for a family meeting. Addendum: Patient now has few suicidal urges and wants to do target behaviors. She reviewed skills with me to "get through" the rest of her week at home and at work. She notes that level of urges right now is manageable for her, and she believes she is improving. Which of the following ICD-10-CM and CPT code sets is correct for reporting the outpatient services provided to this patient? a. F33.9, F43.12, F10.20, F60.3, 99213, 90836 b. F33.1, F43.12, F10.20, F60.3, R45.851, 90845 C. F33.1, F43.12, F10.20, F60.3, 90834 d. F33.1, F43.12, F10.20, F60.3, R45.851, 90834