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[ANSWERED] 25 yo Russian female evaluated for psychiatric evaluation referred from her retiring practitioner for PTSD

Assignment 1: Evaluation and Management (E/M)

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.

For this Assignment, you will review evaluation and management (E/M) documentation for a patient and perform a crosswalk of codes from DSM-5-TR to ICD-10.

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.

Boards of Nursing vs. Professional Nurse Associations

Rubric Detail

Select Grid View or List View to change the rubric’s layout.

Name: NRNP_6675_Week2_Assignment1_Rubric

  Excellent

90%–100%

Good

80%–89%

Fair

70%–79%

Poor

0%–69%

In the E/M patient case scenario provided:

 

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

18 (18%) – 20 (20%)

DSM-5 and ICD-10 codes assigned to the scenario are correct, with no more than a minor error.

16 (16%) – 17 (17%)

DSM-5 and ICD-10 codes assigned to the scenario are mostly correct, with a few minor errors.

14 (14%) – 15 (15%)

DSM-5 and ICD-10 codes assigned to the scenario contain several errors.

0 (0%) – 13 (13%)

DSM-5 and ICD-10 codes assigned to the scenario contain significant errors, or response is missing.

In 1–2 pages, address the following:

 

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

23 (23%) – 25 (25%)

The response accurately and concisely explains what pertinent documentation information is required to support DSM-5 and ICD-10 coding.

20 (20%) – 22 (22%)

The response accurately explains what pertinent documentation information is required to support DSM-5 and ICD-10 coding.

18 (18%) – 19 (19%)

The response somewhat vaguely or inaccurately explains what pertinent documentation information is required to support DSM-5 and ICD-10 coding.

0 (0%) – 17 (17%)

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.

• Explain what pertinent documentation is missing from the case scenario, and what other information would be helpful to narrow your coding and billing options. 23 (23%) – 25 (25%)

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.

20 (20%) – 22 (22%)

The response accurately identifies the pertinent misssing information from the case scenario and identifies what additional information would narrow coding and billing options.

18 (18%) – 19 (19%)

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.

0 (0%) – 17 (17%)

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.

• Finally, explain how to improve documentation to support coding and billing for maximum reimbursement. 14 (14%) – 15 (15%)

The response accurately and concisely explains how to improve documentation to support coding and billing for maximum reimbursement.

12 (12%) – 13 (13%)

The response accurately explains how to improve documentation to support coding and billing for maximum reimbursement.

11 (11%) – 11 (11%)

The response somewhat vaguely or inaccurately explains how to improve documentation to support coding and billing for maximum reimbursement.

0 (0%) – 10 (10%)

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.

Written 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 (5%) – 5 (5%)

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 (4%) – 4 (4%)

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 (3.5%) – 3.5 (3.5%)

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.

0 (0%) – 3 (3%)

Paragraphs and sentences follow writing standards for flow, continuity, and clarity <60% of the time.

Purpose statement, introduction, and conclusion were not provided.

Written Expression and Formatting – English Writing Standards:

 

Correct grammar, mechanics, and proper punctuation

5 (5%) – 5 (5%)

Uses correct grammar, spelling, and punctuation with no errors

4 (4%) – 4 (4%)

Contains 1-2 grammar, spelling, and punctuation errors

3.5 (3.5%) – 3.5 (3.5%)

Contains 3-4 grammar, spelling, and punctuation errors

0 (0%) – 3 (3%)

Contains five or more grammar, spelling, and punctuation errors that interfere with the reader’s understanding

Written Expression and Formatting –

The paper follows correct APA format for parenthetical/in-text citations and reference list.

5 (5%) – 5 (5%)

Uses correct APA format with no errors

4 (4%) – 4 (4%)

Contains 1-2 APA format errors

3.5 (3.5%) – 3.5 (3.5%)

Contains 3-4 APA format errors

0 (0%) – 3 (3%)

Contains five or more APA format errors

Total Points: 100

Expert Answer and Explanation

Pathways Mental Health

Psychiatric Patient Evaluation

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
  1. ADHD (DSM-5 314.01 (ICD-F90-CM)
  2. PTSD (DSM-5 81 (ICD- F43.10-CM)
  3. Anxiety disorder (DSM-5 300.02 (ICD-F41.9-CM)
  4. Major Depressive disorder (ICD-F32.9-CM)
  5. Substance abuse disorder (ICD-F19.10-CM)
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

· Required information to Support Coding

Caregivers need the following information to support the DSM-5 and ICD-10 codes they have proposed. The first and key information is the chief complaint. Caregivers can predict what is affecting the health of patients by recording their chief complaint. The second information is the history of present illness. When collecting data about this section, a nurse can paint a picture about problems the patient is experiencing. The information is vital for coding and billing analysis. Another information that is needed to support the coding is the patient’s presenting symptoms. In this case, the codes in the diagnosis impression have been developed based on presenting symptoms the patient has provided in the HPI section. American Psychiatric Association (2013) notes that people with ADHD often loss this easily, can be frustrated easily, and lacks concentration. The patient in the case has reported all these symptoms. The coding can also be supported by mental status exam. For instance, the mental status exam in the case study shows that the patient is mild anxious, mild irritable, and shows some level of restlessness. The information was used to build the codes.

· Missing Information

The healthcare professional who worked on this documentation included most of the information in the document. However, there are some key information missing that would have made the document rich and narrow billing and coding. One of the data that is missing is review of symptoms. Based on the client’s chief complaint, she wanted to undergo full medical check-up, hence review of symptoms should have been done and documented. Review of symptoms will show the caregiver that the symptoms experienced by the client are not pathophysiological, but psychological problems. The patient’s psychiatric and neurological assessment should have been included in the review of symptoms. Another information that should not miss is the patient’s respiratory and cardiovascular systems’ state of health. Another crucial information that is missing in the document is the patient’s family health history. The nurse should have included this information to determine whether the patient’s problem is a family issue or not. Another missing information is patient’s immunization history and allergies she is suffering.

· Improving Documentation

Documentation to support coding and billing can be improved through the following strategies. First, the document should be developed in a way that even an individual with less knowledge in healthcare issues can understand its contents. Stewart et al. (2017) note that nurses making the entries should know that people who are going to read the document to not have the same knowledge as them. Documentation can be improved by ensuring that the information included in the document should be accurate and factual. Documentation can also be improved by providing patient data in an objective and fair manner. In other words, nurses should be objective and professional while creating the document (Lorenzetti et al., 2018). The document should also reflect the level of care being received by the patient when at the time they are in the facility.  Nurses should also note their grammar when creating clinical document to ensure that they have effectively communicated their message. For instance, they should ensure that the statements in the document have as few passive words as possible.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.

Lorenzetti, D. L., Quan, H., Lucyk, K., Cunningham, C., Hennessy, D., Jiang, J., & Beck, C. A. (2018). Strategies for improving physician documentation in the emergency department: a systematic review. BMC emergency medicine18(1), 1-12. https://link.springer.com/article/10.1186/s12873-018-0188-z

Stewart, K., Doody, O., Bailey, M., & Moran, S. (2017). Improving the quality of nursing documentation in a palliative care setting: a quality improvement initiative. International journal of palliative nursing23(12), 577-585. https://doi.org/10.12968/ijpn.2017.23.12.577

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25 yo Russian female evaluated for psychiatric evaluation referred from her retiring practitioner for PTSD, ADHD, Stimulant Use Disorder, in remission

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