Instructions

Identifying Information

Time spent for evaluation: 0900am-0957am

Chief Complaint

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

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

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):

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

Psychosocial History

Employed at local tanning bed salon

Education: High School Diploma

Denied current legal issues.

Suicide / HOmicide Risk Assessment

• 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

Mental Status Examination

Clinical Impression

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]

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Treatment Plan

• 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.

• 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.

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Instructions

Identifying Information

Time spent for evaluation: 0900am-0957am

Chief Complaint

HPI

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

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

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):

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

Psychosocial History

Employed at local tanning bed salon

Education: High School Diploma

Denied current legal issues.

Suicide / HOmicide Risk Assessment

• 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

Mental Status Examination

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

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

PTSD & ADHD

PTSD:

• DSM-5 diagnostic code: 309.81 (F43.10) (APA, 2013)
• ICD-10 code: F43.10 (ICM10Data.com, n.d.-a)

ADHD (combined presentation):

• DSM-5 code: 314.01 (F90.2) (APA, 2013)
• ICD-10 code: F90.2 (ICM10Data.com, n.d.-b)

Treatment Plan

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 decreased re-experiencing, hyperarousal, and avoidance symptoms; monitor for improved concentration, fewer mistakes, less forgetful

2)       Education: Risks and benefits of medications are discussed including non-treatment. Potential side effects of medications discussed.

Verbal informed consent was obtained.

Not to drive or operate dangerous machinery if feeling sedated.

Not to stop the medication abruptly without discussing it 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.

The ICD-10 coding system is used to classify diseases and aid in billing and payment. According to Leon-Chisen (2018), it stands for the tenth revision of the International Classification of Diseases, Clinical Modification.

The information needed in records to complement DSM-5 and ICD-10 classification usually defines what was done to the client and whether the interventions were provided as an outpatient or inpatient.

It’s worth noting, though, that the DSM-5 helps clinicians diagnose more exactly, whereas the ICD-10 helps them classify and bill for payment much more correctly.

This relevant information is that there must be a match in the DSM-5 and ICD-10 codes, it must be indicated whether the client is an inpatient or an outpatient, the procedure or intervention done must be stated exactly and unambiguously including the amount of time it took to do it, there has to be a maximum of 7 alphanumeric characters in the ICD-10 code, and there must be a provision for clinician query process to find out answers to unclear parts of the billing and coding.

The Missing Information According to the resented Case

The following information is missing from the documentation of the case scenario presented:

1. The age at which the ADHD symptoms first appeared. This is because treatment plans for childhood-onset and adult-onset ADHD may differ (Sadock et al., 2015).
2. The duration of the patient’s treatment with fluoxetine and atomoxetine. This, too, may have an impact on the treatment approach, as additional medications may be considered if the therapeutic effect is delayed or non-existent.

Given the preceding observation, further information about the length of time the patient will be on therapy in weeks as well as the duration of each session might be valuable in restricting the coding and billing possibilities.

It would also be beneficial to know if the practitioner performed any more testing to get at the diagnosis.

Improving Documentation for Better Coding and Billing

The quest for higher income for both the practitioner and the organization is centered on proper coding and billing. The following are some of the tactics the business can take to improve billing and coding so that reimbursement claims generate more revenue:

1. Having a designated person whose duty it is to countercheck claims and follow up on any claims that have been denied and need to be resubmitted. This is due to the fact that, as humans, we will occasionally fail to properly document something. When filling out the details in the electronic health record (EHR) system, certain information may have been overlooked.
2. Keeping up with changes in billing and coding protocols that occur from time to time. This guarantees that the organization’s billing and coding methods are up to date.
3. Ensuring that any deadlines established by stakeholders, such as payers, are reached on time.
4. Appointment of a coder to assist physicians with coding so that crucial information required for seamless and better reimbursement is not overlooked. Clinicians, such as physicians, frequently overlook vital information because they believe it is unimportant.
5. Ascertaining that each patient’s primary and secondary payers are identified.
6. Verifying benefits before administering any treatment to avoid administering treatment that is not covered, causing the claim to be refused.