Explain what pertinent information, generally, is required in documentation to support DSM-5-TR and ICD-10 coding

TO PREPARE
Review this week’s Learning Resources on coding, billing, reimbursement.
Review the E/M patient case scenario provided.

THE ASSIGNMENT
Assign DSM-5-TR and ICD-10 codes to services based upon the patient case scenario.

Then, in 1–2 pages address the following. You may add your narrative answers to these questions to the bottom of the case scenario document and submit altogether as one document.

– Explain what pertinent information, generally, is required in documentation to support DSM-5-TR and ICD-10 coding.
– Explain what pertinent documentation is missing from the case scenario, and what other information would be helpful to narrow your coding and billing options.
– Finally, explain how to improve documentation to support coding and billing for maximum reimbursement.

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