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Explain what pertinent documentation is missing from the case scenario and what other information would be helpful to narrow your coding and billing options

Assignment 1: Evaluation and Management (E/M)

Explain what pertinent documentation is missing from the case scenario and what other information would be helpful to narrow your coding and billing options

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 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 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.
By Day 7 of Week 2

Submit your Assignment.

Submission and Grading Information

To submit your completed Assignment for review and grading, do the following:

  • Please save your Assignment using the naming convention “WK2Assgn1+last name+first initial.(extension)” as the name.
  • Click the Week 2 Assignment 1 Rubric to review the Grading Criteria for the Assignment.
  • Click the Week 2 Assignment 1 link. You will also be able to “View Rubric” for grading criteria from this area.
  • Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK2Assgn1+last name+first initial.(extension)” and click Open.
  • If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database.
  • Click on the Submit button to complete your submission.
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