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.
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.
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
American Psychiatric Association. (2020). 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.
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.
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.
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.
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-
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
Entered mental health system when she was age 19 after raped by a stranger during a
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
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
Cocaine Y last use 2015
Prescription stimulants Y last use 2015
Sedative/sleeping pills N
Street Opioids N
Prescription opioids N
Other: specify (spice, K2, bath salts,
Y reports one-time ecstasy use in 2015
Any history of substance related:
Longest sobriety reported since 2015—stayed sober maintaining sponsor, sober friends, and
Page | 4 Walden University, LLC
SUICIDE / HOMICIDE
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
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
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.
[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
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
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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