Evaluation and management (E/M) documentation for a patient and a crosswalk of codes from DSM-5-TR to ICD-10
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.
Resources
Be sure to review the Learning Resources before completing this activity. Click the weekly resources link to access the resources.
WEEKLY RESOURCES
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.
By Day 7 of Week 2
Submit your Assignment.
submission information
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- To submit your completed assignment, save your Assignment as WK2Assgn1_LastName_Firstinitial
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Rubric
| Criteria | Ratings | Pts |
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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.
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20 to >17.0 ptsExcellent 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 ptsGood 80%–89%DSM-5 and ICD-10 codes assigned to the scenario are mostly correct, with a few minor errors.
15 to >13.0 ptsFair 70%–79%DSM-5 and ICD-10 codes assigned to the scenario contain several errors.
13 to >0 ptsPoor 0%–69%DSM-5 and ICD-10 codes assigned to the scenario contain significant errors, or response is missing.
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20 pts
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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.
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25 to >22.0 ptsExcellent 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 ptsGood 80%–89%The response accurately explains what pertinent documentation information is required to support DSM-5 and ICD-10 coding.
19 to >17.0 ptsFair 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 ptsPoor 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.
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25 pts
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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.
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25 to >22.0 ptsExcellent 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 ptsGood 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 ptsFair 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 ptsPoor 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.
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25 pts
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This criterion is linked to a Learning Outcome• Finally, explain how to improve documentation to support coding and billing for maximum reimbursement.
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15 to >13.0 ptsExcellent 90%–100%The response accurately and concisely explains how to improve documentation to support coding and billing for maximum reimbursement.
13 to >11.0 ptsGood 80%–89%The response accurately explains how to improve documentation to support coding and billing for maximum reimbursement.
11 to >10.0 ptsFair 70%–79%The response somewhat vaguely or inaccurately explains how to improve documentation to support coding and billing for maximum reimbursement.
10 to >0 ptsPoor 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.
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15 pts
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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.
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5 to >4.0 ptsExcellent 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 ptsGood 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 ptsFair 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 ptsPoor 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.
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5 pts
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This criterion is linked to a Learning OutcomeWritten Expression and Formatting – English Writing Standards: Correct grammar, mechanics, and proper punctuation
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5 to >4.0 ptsExcellent 90%–100%Uses correct grammar, spelling, and punctuation with no errors
4 to >3.5 ptsGood 80%–89%Contains 1-2 grammar, spelling, and punctuation errors
3.5 to >3.0 ptsFair 70%–79%Contains 3-4 grammar, spelling, and punctuation errors
3 to >0 ptsPoor 0%–69%Contains five or more grammar, spelling, and punctuation errors that interfere with the reader’s understanding
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5 pts
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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.
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5 to >4.0 ptsExcellent 90%–100%Uses correct APA format with no errors
4 to >3.5 ptsGood 80%–89%Contains 1-2 APA format errors
3.5 to >3.0 ptsFair 70%–79%Contains 3-4 APA format errors
3 to >0 ptsPoor 0%–69%Contains five or more APA format errors
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5 pts
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Psychiatric Patient Evaluation
| 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 |
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| 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. |
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| 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 |
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| 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 |
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| Substance Use History |
Have you used/abused any of the following (include frequency/amt/last use):
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 |
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| 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. |
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| 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 |
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| 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. |
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| Diagnostic: Impression: | The act of rendering care to the patients by the provider can be consultation, examination, or counseling (Wiggins et al., 2019). Patient care services can occur in an acute care setting, emergency room, outpatient, rehabilitation, long-term care, hospice, and home care. When services are rendered, reimbursement is expected from the payers. Clinicians use the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) as a tool to primarily assess and diagnose patients with mental health disorders (Wiggins et al., 2019). It is important to note that the guidelines contained in DSM-5 are not for treating patients, and the codes are not for billing patients after rendering services. The International Classification of Diseases, Tenth Revision, and Clinical Modification (ICD-10) are tools the provider uses as a guide to bill the payer. Billing and service reimbursement is sent to the payer in a coded format. A delay, denial, or partial payment can result if services are improperly coded. The DSM-5 helps clinicians to assess and diagnose patients, while the ICD-10 guides clinicians with the correct coding of care and services given to the patient. The provider uses reimbursement codes from ICD-10 to add value to the services rendered to patients based on the level and quality of services. A reimbursement claim must be appropriately coded, as codes convey the level of care given. Analyzing the scenario in this assignment, correctly coding the services given and the time spent with the patient is vital to proper reimbursement. A unique code like 90837 is used for any time the clinician spends with the patient above 53 minutes. The time spent with the patient in this scenario was 57 minutes; therefore, the code 90792 applies, while F41.1 is the code for medical services of the diagnosis of generalized anxiety post-PTSD (Khera et al., 2018)
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| 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. |
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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.
When patient care is given, attention to detail and linking all the pieces is crucial. This is vital because maximum reimbursement depends on connecting the dots when filing claims. (Nguyen et al., 2018). Often, the insurance companies or payer may demand extra proof to buttress the claims or show that the level of care reimbursement filed met the level coded/billed. When pertinent information is missing during coding, reimbursement can be delayed, denied, or result in low reimbursement (Nguyen et al., 2018). Patient assessment, including physical examinations, medical decision-making, counseling, care coordination, presenting condition, and time, are essential in DSM-5 and ICD-10 coding for proper billing (Nguyen et al., 2018). Translating all these services into a billable format is essential in coding. The clinician should pay attention to a primary complaint (cc) and current illness history (HPI), a thorough review of systems (ROS), and any pertinent previous, family, social history, patient’s medical history, drug abuse histories, suicide risk assessments, mental health examinations, proposed treatment plans and amount of time spent doing an assessment (Nguyen et al., 2018). In this scenario involving assessing a 25-year-old Russian female patient, pertinent information was captured, but a detailed review of the patient’s health records to authenticate the diagnosis is recommended. The vital information to aid proper coding, billing, and reimbursement and assist with DSM-5 diagnosis. Documentation in this scenario can be summarized as physicians’ descriptions, patients’ presenting symptoms, and other tips for diagnosing mental illness (Nguyen et al., 2018).
Finally, explain how to improve documentation to support coding and billing for maximum reimbursement.
The use of technology in healthcare practice has transformed documentation to support coding and billing. Using electronic medical records (EMR), billing and coding is faster and more accurate. The transformation of coding and billing through technology has improved how coders streamline claims to meet the company’s mission and vision. Identification of accounting, updating, uploading, and extracting data is simple, faster, and less stressful. It enables good work ethics and co-ordinations among coders and documentation specialists due to enhancement in technology. Investing in personnel to champion and support the employees is another strategy to improve documentation. Clinical managers fall under this category as they will train and re-train employees in advancing technology at all levels. Integrating coding roles in surveys to monitor compliance will also help keep the consciousness of coders on doing the right thing to avoid being tagged.
References
American Psychiatric Association. (2022). ICD-10-CM Codes Update Links to an external site.. https://www.psychiatry.org/psychiatrists/practice/dsm/updates-to-dsm/updates-to-dsm-5-tr-criteria-text
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 Khera, R., Dorsey, K. B., & Krumholz, H. M. (2018). Transition to the ICD-10 in the United States: an emerging data chasm. Jama, 320(2), 133-134. https://jamanetwork.com/journals/jama/article-abstract/2683806
Nguyen, A. N., Truran, D., Kemp, M., Koopman, B., Conlan, D., O’Dwyer, J., … & Green, D. (2018). Computer-assisted diagnostic coding: effectiveness of an NLP-based approach using SNOMED CT to ICD-10 mappings. In AMIA Annual Symposium Proceedings (Vol. 2018, p. 807). American Medical Informatics Association.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6371260/
Clarke DE, Narrow WE, Regier DA, et al. DSM-5 field trials in the United States and Canada, Part I: study design, sampling strategy, implementation, and analytic approaches. Am J Psychiatry. 2013;170:43-58.
World Health Organization. ICD-10 Classification of mental and behavioral disorders. Diagnostic criteria for research. Geneva: World Health Organization; 1993
Wiggins, L. D., Rice, C. E., Barger, B., Soke, G. N., Lee, L. C., Moody, E., Edmondson-Pretzel, R., & Levy, S. E. (2019, March 8). DSM-5 criteria for autism spectrum disorder maximizes diagnostic sensitivity and specificity in preschool children. Social Psychiatry and Psychiatric Epidemiology, 54(6), 693–701. https://doi.org/10.1007/s00127-019-
01674-1 Evaluation and management (E/M) documentation for a patient and a crosswalk of codes from DSM-5-TR to ICD-10