Evaluation and management (e/m)

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Insurance coding and billing is complex, but it boils down to how to accurately apply a code, or CPT (current procedural terminology), to the service that you provided. The payer then reimburses the service at a certain rate. As a provider, you will have to understand what codes to use and what documentation is necessary to support coding.

Review evaluation and management (E/M) documentation for a patient and perform a crosswalk of codes from DSM-5-TR to ICD-10. 

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 codes

Links to an external site.
. https://www.psychiatry.org/psychiatrists/practice/dsm/updates-to-dsm-5

· American Psychiatric Association. (2013). 


Insurance implications of DSM-5Links to an external site.


https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM_Insurance-Implications-of-DSM-5.pdf

· Clicking on this link will initiate the download of the PDF.

· American Psychiatric Association. (2020). 


Coding and reimbursement

Links to an external site.
.
https://www.psychiatry.org/psychiatrists/practice/practice-management/coding-reimbursement-medicare-and-medicaid/coding-and-reimbursement

· American Psychiatric Association. (2022). Numerical listing of DSM-5 diagnoses and codes (ICD-10-CM). 

In 
Diagnostic and statistical manual of mental disordersLinks to an external site.

 (5th ed., text rev.). https://go.openathens.net/redirector/waldenu.edu?url=https://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425787

· Buppert, C. (2021). 
Nurse practitioner’s business practice and legal guide (7th ed.). Jones & Bartlett Learning.

· Chapter 9, “Reimbursement for Nurse Practitioner Services”

· Centers for Medicare & Medicaid Services. (2020). 


Your billing responsibilities

Links 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.

· Chapter 15, “Reimbursement for Nurse Practitioner Services”

· Walden University Academic Skills Center. (2017). 


Developing SMART goals

Links to an external site.
. https://academicguides.waldenu.edu/ld.php?content_id=51901492

· Zakhari, R. (2021). 
The psychiatric-mental health nurse practitioner certification review manual. Springer Publishing Company.  

· Chapter 4 “Neuroanatomy, Physiology, and Mental Illness”

PSYCHIATRIC PATIENT EVALUATION

INSTRUCTIONS: Use the following case template to complete this Assignment.

· On the Diagnostic Impression, 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

YES/NO

Frequency/Last Use

Tobacco products

Y

ETHOH

Y

Cannabis

N

Cocaine

Y

Last use 2015

Prescription stimulants

Y

Last use 2015

Methamphetamine

N

Inhalants

N

Sedative/Sleeping Pill

N

Hallucinogens

N

Street Opioid

N

Prescription Opioid

N

Other: specify (spice, K2, bath salts, etc.)

Y

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.

MENTAL STATUS EXAMINATION
She is a 25 yr.-old 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.

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.   

REFERENCES
[ADD APA-FORMATTED CITATIONS FOR ANY SOURCES YOU REFERENCED

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