Explain what pertinent information, generally, is required in documentation to support DSM-5-TR and ICD-10 coding
Order Instructions
LEARNING RESOURCES
Required Readings
• American Psychiatric Association. (2022). ICD-10-CM Codes UpdateLinks to an external site.. https://www.psychiatry.org/psychiatrists/practice/dsm/updates-to-dsm/updates-to-dsm-5-tr-criteria-text
• American Psychiatric Association. (2022). Changes to ICD-10-CM Codes for DSM-5 DiagnosesLinks to an external site.. https://www.psychiatry.org/psychiatrists/practice/dsm/updates-to-dsm/coding-updates
• American Psychiatric Association. (2020). Updates to DSM–5 criteria, text and ICD-10 codesLinks to an external site.. https://www.psychiatry.org/psychiatrists/practice/dsm/updates-to-dsm-5
• American Psychiatric Association. (2020). Coding and reimbursementLinks to an external site..
https://www.psychiatry.org/psychiatrists/practice/practice-management/coding-reimbursement-medicare-and-medicaid/coding-and-reimbursement
• Buppert, C. (2021). Nurse practitioner’s business practice and legal guide (7th ed.). Jones & Bartlett Learning.
o Chapter 9, “Reimbursement for Nurse Practitioner Services”
• Centers for Medicare & Medicaid Services. (2020). Your billing responsibilitiesLinks to an external site.. https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/ProviderServices/Your-Billing-Responsibilities
• Stewart, J. G., & DeNisco, S. M. (2019). Role development for the nurse practitioner (2nd ed.). Jones & Bartlett Learning.
•
• Zakhari, R. (2021). The psychiatric-mental health nurse practitioner certification review manual. Springer Publishing Company.
o Chapter 4 “Neuroanatomy, Physiology, and Mental Illness”
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.
Review the E/M patient case scenario provided
Pathways Mental Health
NETSMART
Instructions Use the following case template to complete Week 2 Assignment 1. On page 5, assign DSM-5-TR and Updated ICD-10 codes to the services documented. You will add your narrative answers to the assignment questions to the bottom of this template and submit altogether as one document.
Identifying Information Identification was verified by stating of their name and date of birth.
Time spent for evaluation: 0900am-0957am
Chief Complaint “My other provider retired. I don’t think I’m doing so well.”
HPI 25 yo Russian female evaluated for psychiatric evaluation referred from her retiring practitioner for PTSD, ADHD, Stimulant Use Disorder, in remission. She is currently prescribed fluoxetine 20mg po daily for PTSD, atomoxetine 80mg po daily for ADHD.
Today, client denied symptoms of depression, denied anergia, anhedonia, amotivation, no anxiety, denied frequent worry, reports feeling restlessness, no reported panic symptoms, no reported obsessive/compulsive behaviors. Client denies active SI/HI ideations, plans or intent. There is no evidence of psychosis or delusional thinking. Client denied past episodes of hypomania, hyperactivity, erratic/excessive spending, involvement in dangerous activities, self-inflated ego, grandiosity, or promiscuity. Client reports increased irritability and easily frustrated, loses things easily, makes mistakes, hard time focusing and concentrating, affecting her job. Has low frustration tolerance, sleeping 5–6 hrs/24hrs reports nightmares of previous rape, isolates, fearful to go outside, has missed several days of work, appetite decreased. She has somatic concerns with GI upset and headaches. Client denied any current binging/purging behaviors, denied withholding food from self or engaging in anorexic behaviors. No self-mutilation behaviors.
Diagnostic Screening Results Screen of symptoms in the past 2 weeks:
PHQ 9 = 0 with symptoms rated as no difficulty in functioning
Interpretation of Total Score
Total Score Depression Severity 1-4 Minimal depression 5-9 Mild depression 10-14 Moderate depression 15-19 Moderately severe depression 20-27 Severe depression
GAD 7 = 2 with symptoms rated as no difficulty in functioning
Interpreting the Total Score:
Total Score Interpretation ≥10 Possible diagnosis of GAD; confirm by further evaluation 5 Mild Anxiety 10 Moderate anxiety 15 Severe anxiety
MDQ screen negative
PCL-5 Screen 32
Past Psychiatric and Substance Use Treatment • Entered mental health system when she was age 19 after raped by a stranger during a house burglary.
• Previous Psychiatric Hospitalizations: denied
• Previous Detox/Residential treatments: one for abuse of stimulants and cocaine in 2015
• Previous psychotropic medication trials: sertraline (became suicidal), trazodone (worsened nightmares), bupropion (became suicidal), Adderall (began abusing)
• Previous mental health diagnosis per client/medical record: GAD, Unspecified Trauma, PTSD, Stimulant use disorder, ADHD confirmed by school records
Substance Use History Have you used/abused any of the following (include frequency/amt/last use):
Substance Y/N Frequency/Last Use
Tobacco products Y ½
ETOH Y last drink 2 weeks ago, reports drinks 1-2 times monthly one drink socially
Cannabis N
Cocaine Y last use 2015
Prescription stimulants Y last use 2015
Methamphetamine N
Inhalants N
Sedative/sleeping pills N
Hallucinogens N
Street Opioids N
Prescription opioids N
Other: specify (spice, K2, bath salts, etc.) Y reports one-time ecstasy use in 2015
Any history of substance related:
• Blackouts: +
• Tremors: –
• DUI: –
• D/T’s: –
• Seizures: –
Longest sobriety reported since 2015—stayed sober maintaining sponsor, sober friends, and meetings
Psychosocial History Client was raised by adoptive parents since age 6; from Russian orphanage. She has unknown siblings. She is single; has no children.
Employed at local tanning bed salon
Education: High School Diploma
Denied current legal issues.
Suicide / HOmicide Risk Assessment RISK FACTORS FOR SUICIDE:
• Suicidal Ideas or plans – no
• Suicide gestures in past – no
• Psychiatric diagnosis – yes
• Physical Illness (chronic, medical) – no
• Childhood trauma – yes
• Cognition not intact – no
• Support system – yes
• Unemployment – no
• Stressful life events – yes
• Physical abuse – yes
• Sexual abuse – yes
• Family history of suicide – unknown
• Family history of mental illness – unknown
• Hopelessness – no
• Gender – female
• Marital status – single
• White race
• Access to means
• Substance abuse – in remission
PROTECTIVE FACTORS FOR SUICIDE:
• Absence of psychosis – yes
• Access to adequate health care – yes
• Advice & help seeking – yes
• Resourcefulness/Survival skills – yes
• Children – no
• Sense of responsibility – yes
• Pregnancy – no; last menses one week ago, has Norplant
• Spirituality – yes
• Life satisfaction – “fair amount”
• Positive coping skills – yes
• Positive social support – yes
• Positive therapeutic relationship – yes
• Future oriented – yes
Suicide Inquiry: Denies active suicidal ideations, intentions, or plans. Denies recent self-harm behavior. Talks futuristically. Denied history of suicidal/homicidal ideation/gestures; denied history of self-mutilation behaviors
Global Suicide Risk Assessment: The client is found to be at low risk of suicide or violence, however, risk of lethality increased under context of drugs/alcohol.
No required SAFETY PLAN related to low risk
Mental Status Examination She is a 25 yo Russian female who looks her stated age. She is cooperative with examiner. She is neatly groomed and clean, dressed appropriately. There is mild psychomotor restlessness. Her speech is clear, coherent, normal in volume and tone, has strong cultural accent. Her thought process is ruminative. There is no evidence of looseness of association or flight of ideas. Her mood is anxious, mildly irritable, and her affect appropriate to her mood. She was smiling at times in an appropriate manner. She denies any auditory or visual hallucinations. There is no evidence of any delusional thinking. She denies any current suicidal or homicidal ideation. Cognitively, She is alert and oriented to all spheres. Her recent and remote memory is intact. Her concentration is fair. Her insight is good.
Clinical Impression Client is a 25 yo Russian female who presents with history of treatment for PTSD, ADHD, Stimulant use Disorder, in remission.
Moods are anxious and irritable. She has ongoing reported symptoms of re-experiencing, avoidance, and hyperarousal of her past trauma experiences; ongoing subsyndromal symptoms related to her past ADHD diagnosis and exacerbated by her PTSD diagnosis. She denied vegetative symptoms of depression, no evident mania/hypomania, no psychosis, denied anxiety symptoms. Denied current cravings for drugs/alcohol, exhibits no withdrawal symptoms, has somatic concerns of GI upset and headaches.
At the time of disposition, the client adamantly denies SI/HI ideations, plans or intent and has the ability to determine right from wrong, and can anticipate the potential consequences of behaviors and actions. She is a low risk for self-harm based on her current clinical presentation and her risk and protective factors.
Diagnostic Impression [Student to provide DSM-5-TR and Updated ICD-10 coding]
Double click inside this text box to add/edit text. Delete placeholder text when you add your answers.
Treatment Plan 1) Medication:
• Increase fluoxetine 40mg po daily for PTSD #30 1 RF
• Continue with atomoxetine 80mg po daily for ADHD. #30 1 RF
Instructed to call and report any adverse reactions.
Future Plan: monitor for decrease re-experiencing, hyperarousal, and avoidance symptoms; monitor for improved concentration, less mistakes, less forgetful
2) Education: Risks and benefits of medications are discussed including non-treatment. Potential side effects of medications discussed. Verbal informed consent obtained.
Not to drive or operate dangerous machinery if feeling sedated.
Not to stop medication abruptly without discussing with providers.
Discussed risks of mixing medications with OTC drugs, herbal, alcohol/illegal drugs. Instructed to avoid this practice. Praised and Encouraged ongoing abstinence. Maintain support system, sponsors, and meetings.
Discussed how drugs/ETOH affects mental health, physical health, sleep architecture.
3) Patient was educated about therapy and services of the MHC including emergent care. Referral was sent via email to therapy team for PET treatment.
4) Patient has emergency numbers: Emergency Services 911, the national Crisis Line 800-273-TALK, the MHC Crisis Clinic. Patient was instructed to go to nearest ER or call 911 if they become actively suicidal and/or homicidal.
5) Time allowed for questions and answers provided. Provided supportive listening. Patient appeared to understand discussion and appears to have capacity for decision making via verbal conversation.
6) RTC in 30 days
7) Follow up with PCP for GI upset and headaches, reviewed PCP history and physical dated one week ago and include lab results
Patient is amenable with this plan and agrees to follow treatment regimen as discussed.
Narrative Answers
[In 1-2 pages, address the following:
• Explain what pertinent information, generally, is required in documentation to support DSM-5-TR and Updated 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.]
Add your answers here. Delete instructions and placeholder text when you add your answers.
REFERENCES
[Add APA-formatted citations for any sources you referenced
Delete instructions and placeholder text when you add your citations.
Rubric
_Assignment1_Rubric
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeIn the E/M patient case scenario provided:• Assign DSM-5 and ICD-10 codes to services based upon the patient case scenario. 20 to >17.0 pts
Excellent 90%–100%
DSM-5 and ICD-10 codes assigned to the scenario are correct, with no more than a minor error. 17 to >15.0 pts
Good 80%–89%
DSM-5 and ICD-10 codes assigned to the scenario are mostly correct, with a few minor errors. 15 to >13.0 pts
Fair 70%–79%
DSM-5 and ICD-10 codes assigned to the scenario contain several errors. 13 to >0 pts
Poor 0%–69%
DSM-5 and ICD-10 codes assigned to the scenario contain significant errors, or response is missing.
20 pts
This criterion is linked to a Learning OutcomeIn 1–2 pages, address the following: • Explain what pertinent information, generally, is required in documentation to support DSM-5 and ICD-10 coding. 25 to >22.0 pts
Excellent 90%–100%
The response accurately and concisely explains what pertinent documentation information is required to support DSM-5 and ICD-10 coding. 22 to >19.0 pts
Good 80%–89%
The response accurately explains what pertinent documentation information is required to support DSM-5 and ICD-10 coding. 19 to >17.0 pts
Fair 70%–79%
The response somewhat vaguely or inaccurately explains what pertinent documentation information is required to support DSM-5 and ICD-10 coding. 17 to >0 pts
Poor 0%–69%
The response vaguely or inaccurately explains what pertinent documentation information is required to support DSM-5 and ICD-10 coding, or the explanation is incomplete or missing.
25 pts
This criterion is linked to a Learning Outcome• Explain what pertinent documentation is missing from the case scenario, and what other information would be helpful to narrow your coding and billing options. 25 to >22.0 pts
Excellent 90%–100%
The response accurately and concisely identifies the pertinent misssing information from the case scenario and clearly identifies what additional information would narrow coding and billing options. 22 to >19.0 pts
Good 80%–89%
The response accurately identifies the pertinent misssing information from the case scenario and identifies what additional information would narrow coding and billing options. 19 to >17.0 pts
Fair 70%–79%
The response somewhat vaguely or inaccurately identifies the pertinent misssing information from the case scenario and identifies what additional information would narrow coding and billing options. 17 to >0 pts
Poor 0%–69%
The response vaguely or inaccurately identifies the pertinent misssing information from the case scenario or partially identifies what additional information would narrow coding and billing options, or this information is incomplete or missing.
25 pts
This criterion is linked to a Learning Outcome• Finally, explain how to improve documentation to support coding and billing for maximum reimbursement. 15 to >13.0 pts
Excellent 90%–100%
The response accurately and concisely explains how to improve documentation to support coding and billing for maximum reimbursement. 13 to >11.0 pts
Good 80%–89%
The response accurately explains how to improve documentation to support coding and billing for maximum reimbursement. 11 to >10.0 pts
Fair 70%–79%
The response somewhat vaguely or inaccurately explains how to improve documentation to support coding and billing for maximum reimbursement. 10 to >0 pts
Poor 0%–69%
The response vaguely or inaccurately explains how to improve documentation to support coding and billing for maximum reimbursement, or response may be incomplete or missing.
15 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria. 5 to >4.0 pts
Excellent 90%–100%
Paragraphs and sentences follow writing standards for flow, continuity, and clarity…. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria. 4 to >3.5 pts
Good 80%–89%
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time…. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive. 3.5 to >3.0 pts
Fair 70%–79%
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time…. Purpose, introduction, and conclusion of the assignment are vague or off topic. 3 to >0 pts
Poor 0%–69%
Paragraphs and sentences follow writing standards for flow, continuity, and clarity <60% of the time…. Purpose statement, introduction, and conclusion were not provided.
5 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – English Writing Standards: Correct grammar, mechanics, and proper punctuation 5 to >4.0 pts
Excellent 90%–100%
Uses correct grammar, spelling, and punctuation with no errors 4 to >3.5 pts
Good 80%–89%
Contains 1-2 grammar, spelling, and punctuation errors 3.5 to >3.0 pts
Fair 70%–79%
Contains 3-4 grammar, spelling, and punctuation errors 3 to >0 pts
Poor 0%–69%
Contains five or more grammar, spelling, and punctuation errors that interfere with the reader’s understanding
5 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – The paper follows correct APA format for parenthetical/in-text citations and reference list. 5 to >4.0 pts
Excellent 90%–100%
Uses correct APA format with no errors 4 to >3.5 pts
Good 80%–89%
Contains 1-2 APA format errors 3.5 to >3.0 pts
Fair 70%–79%
Contains 3-4 APA format errors 3 to >0 pts
Poor 0%–69%
Contains five or more APA format errors
SAMPLE ANSWER
Pertinent information required for DSM-5-TR and ICD-10 coding includes specific details about the patient’s condition, symptoms, medical history, and any treatments or interventions provided. It is essential to document the patient’s signs and symptoms, the severity and duration of the condition, and any underlying medical or psychiatric conditions that may contribute to the patient’s diagnosis. Documentation should also include the patient’s demographic information, such as age, gender, and ethnicity, as these factors may affect the diagnosis and treatment.
In the case scenario provided, there is missing pertinent documentation such as the patient’s past medical history, family history, and social history, which could help narrow down the diagnosis and treatment options. Additionally, specific details about the patient’s current symptoms, such as the duration and severity of the symptoms, are not mentioned, making it difficult to determine the appropriate diagnosis.
To improve documentation to support coding and billing for maximum reimbursement, healthcare providers should ensure that they document all relevant information related to the patient’s condition, including medical history, physical examination, diagnostic tests, and treatment plans. They should use clear and concise language and avoid vague terms or abbreviations that may be unclear to other healthcare professionals.
It is also crucial to document the patient’s response to treatment and any changes in their condition, as this information can help justify the need for ongoing treatment and support for reimbursement purposes. Finally, healthcare providers should ensure that they comply with all relevant coding and billing guidelines to avoid potential errors or denials.
References:
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
World Health Organization. (2016). International statistical classification of diseases and related health problems (10th ed.). Geneva, Switzerland: World Health Organization.
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