DSM-5 and ICD-10 coding
DSM-5 and ICD-10 coding
Insurance coding and billing is complex, but it boils down to how to accurately a
pply 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.
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. |
Complete Answer:
