Evaluation and Management (E/M)

The Assignment

Assign DSM-5 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 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.  

     
Instructions

Use the following case template to complete Week 2   Assignment 1. On page 5, assign DSM-5 and 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 and 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 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.]
Add your answers here. Delete instructions and placeholder   text when you add your answers.

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