EVALUATION AND MANAGEMENT|My course tutor

• 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.

SOLUTION

Patient Case Scenario:
Mrs. Smith is a 58-year-old female who presents to the clinic with complaints of difficulty sleeping, feelings of sadness and hopelessness, and loss of interest in activities she used to enjoy. She reports these symptoms have been present for the past six months and have worsened over time. She denies any suicidal ideation or intent. She reports a history of depression and anxiety and has previously been prescribed medication for these conditions. She reports that her symptoms are negatively impacting her daily functioning and ability to perform her job as a teacher. She denies any recent changes in her life or stressors that could be contributing to her symptoms.