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 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.

American Psychiatric Association. (2020). Updates to DSM–5 criteria, text and ICD-10 codes. https://www.psychiatry.org/psychiatrists/practice/dsm/updates-to-dsm-5

American Psychiatric Association. (2013). Insurance implications of DSM-5. https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM_Insurance-Implications-of-DSM-5.pdf

  • Clicking on this link will initiate the download of the PDF.

American Psychiatric Association. (2020). Coding and reimbursement.

https://www.psychiatry.org/psychiatrists/practice/practice-management/coding-reimbursement-medicare-and-medicaid/coding-and-reimbursement

American Psychiatric Association. (2013). Numerical listing of DSM-5 diagnoses and codes (ICD-10-CM). In Diagnostic and statistical manual of mental disorders (5th ed.). http://dsm.psychiatryonline.org.ezp.waldenulibrary.org/doi/10.1176/appi.books.9780890425596.ICD10Num_list

Buppert, C. (2021). Nurse practitioner’s business practice and legal guide (7th ed.). Jones & Bartlett Learning.

  • Chapter 9, “Reimbursement for Nurse Practitioner Services”

Centers for Medicare & Medicaid Services. (2020). Your billing responsibilities. https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/ProviderServices/Your-Billing-Responsibilities

Stewart, J. G., & DeNisco, S. M. (2019). Role development for the nurse practitioner (2nd ed.). Jones & Bartlett Learning.

  • Chapter 15, “Reimbursement for Nurse Practitioner Services”

Walden University Academic Skills Center. (2017). Developing SMART goals. https://academicguides.waldenu.edu/ld.php?content_id=51901492

Zakhari, R. (2021). The psychiatric-mental health nurse practitioner certification review manual. Springer Publishing Company.  

  • Chapter 4 “Neuroanatomy, Physiology, and Mental Illness”

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

Page | 3 Walden University, LLC
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

Page | 4 Walden University, LLC
PSYCHOSOCIAL
HISTORY

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

Page | 5 Walden University, LLC
MENTAL STATUS
EXAMINATION

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

[STUDENT TO PROVIDE DSM-5 AND ICD-10 CODING]

Double click inside this text box to add/edit text. Delete placeholder text when you add your
answers.

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.

Page | 6 Walden University, LLC

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