Psychiatric Patient Evaluation
Explain what pertinent information, generally, is required in documentation to support DSM-5-TR and Updated ICD-10 coding.
The patient’s case history is examined to gather data that might be utilized to guide coding in the DSM-5-TR and Updated ICD-10. This directly translates into the need of maintaining a record of the patient’s mental disease symptoms. Specifically, when the symptoms initially appeared, how they changed over time, how often they occurred, and how severe they were should all be included in this. Determining whether or whether the patient’s current symptoms are connected to a previous diagnosis they got is of the utmost importance. According to Reed et al. (2019), it is crucial to record any other symptoms that may affect a patient’s cognitive function and behavior while doing a mental status evaluation on them. It is possible that considering the client’s history of drug usage might be helpful when seeking to develop a diagnosis for a condition that is linked to substance misuse. This is what would happen if someone were looking for a condition that was caused by drug usage.

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To ensure that the primary diagnosis is accurate, it is vital to document the patient’s comorbidities as well as the likely diagnosis using the previously established criteria. It is crucial to ascertain if the client seeking therapy is a new patient or whether they have already received treatment for their present mental disorder from another healthcare provider (Horsky et al., 2018). It is vital to find out whether or not the patient has previously undergone therapy if they are a new patient. It is also decisive to find out if the patient has previously had treatment for the mental disease they are now suffering from if they are a new patient. The practice’s new patients include those who haven’t visited a doctor in at least three years (Reed et al., 2019). The appropriate codes must be added to the medical record of a newly admitted patient at the time of admission for them to be correctly invoiced.
Explain what pertinent documentation is missing from the case scenario, and what other information would be helpful to narrow your coding and billing options.
There is a substantial lack of information on the patient’s regular symptoms in the instance we are looking at. This ignorance includes not just the patient’s specific symptoms but also their frequency, the underlying reasons for those symptoms, and any mitigating factors. The patient’s general health is another area where there is a dearth of information. A complete list of likely diagnoses that can be quickly retrieved is not yet available. Even though these specific indicators of symptom severity aid in the classification of the patient’s condition, Horsky et al. (2018) indicates that there are a few other signs of symptom severity that are equally important in diagnosing and classifying a patient’s mental illness. These other symptom intensity predictors are equally important. Furthermore, as they have not been the focus of any research, physiological elements like pain have been ruled out as possible explanations for this phenomenon. This eliminates the possibility of another cause of the patient’s mental illness.
To reduce the number of coding and billing options that patients are presented with, it is essential to gather all relevant patient data. This comprises several additional crucial pieces of information, in addition to details like the patient’s home address, mailing address, workplace, and phone number. To prevent mistakes throughout the coding and billing processes, it is crucial to do a thorough evaluation of the laboratory data as well as the imaging tests, such as X-rays (First et al., 2018). This is because some information about a patient’s health may be revealed by these tests that had not previously been known. Additionally, fixing any incorrect, duplicate, or missing data is of the utmost importance. This also applies to information that was entered erroneously. Data collection must be precise and complete to prevent incorrect coding, which might lead to incorrect charge options.
Finally, explain how to improve documentation to support coding and billing for maximum reimbursement.
The Medical Group Management Association asserts that for a medical practice to enhance its revenue, it is required to keep thorough records that are compliant with all relevant reporting rules, pursue claim denials tenaciously, and submit appeals on time (Reed et al., 2019). The Medical Group Management Association also stresses the need of filing appeals as soon as feasible. There are a total of six different methods that may be used to simplify the optimization of reimbursement using accurate coding and billing standards. The following lists some of these tactics. Esposito et al. (2020) suggest using a broad array of various strategies to increase the accuracy of medical coding. Involving medical and health professionals in the coding process, staying up to date on the most recent coding resources and regulations, conducting thorough reviews of clinician or physician records before coding, and working with a reputable medical assertions firm are a few examples. Other strategies include hiring an internal claim tracker. Furthermore, it is critical to see rejected claims as a chance to grow. 
Esposito, T., Reed, R., Adams, R. C., Fakhry, S., Carey, D., & Crandall, M. L. (2020). Acute Care Surgery Billing, Coding and Documentation Series Part 2: Postoperative Documentation and Coding; Documentation and Coding in Conjunction with Trainees and Advanced Practitioners; Coding Select Procedures. Trauma Surgery & Acute Care Open, 5(1), e000586.
First, M. B., Rebello, T. J., Keeley, J. W., Bhargava, R., Dai, Y., Kulygina, M., Matsumoto, C., Robles, R., Stona, A.-C., & Reed, G. M. (2018). Do mental health professionals use diagnostic classifications the way we think they do? A global survey. World Psychiatry, 17(2), 187–195.
Horsky, J., Drucker, E. A., & Ramelson, H. Z. (2018). Accuracy and Completeness of Clinical Coding Using ICD-10 for Ambulatory Visits. AMIA Annual Symposium Proceedings, 2017, 912–920.
Reed, G. M., First, M. B., Kogan, C. S., Hyman, S. E., Gureje, O., Gaebel, W., Maj, M., Stein, D. J., Maercker, A., Tyrer, P., Claudino, A., Garralda, E., Salvador-Carulla, L., Ray, R., Saunders, J. B., Dua, T., Poznyak, V., Medina-Mora, M. E., Pike, K. M., & Ayuso-Mateos, J. L. (2019). Innovations and changes in the ICD-11 classification of mental, behavioral, and neurodevelopmental disorders. World Psychiatry, 18(1), 3–19.




Use the following case template to complete Week 2 Assignment 1. On page 5, assign DSM-5-TR and Updated 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.”


25 yo Russian female evaluated for psychiatric evaluation was referred from her retiring practitioner for PTSD, ADHD, and Stimulant Use Disorder, in remission. She is currently prescribed fluoxetine 20mg po daily for PTSD, and atomoxetine 80mg po daily for ADHD.

Today, the client denied symptoms of depression, denied anergia, anhedonia, motivation, no anxiety, denied frequent worry, reports feeling restlessness, no reported panic symptoms, and no reported obsessive/compulsive behaviors. The client denies active SI/HI ideations, plans, or intent.

There is no evidence of psychosis or delusional thinking. The client denied past episodes of

hypomania, hyperactivity, erratic/excessive spending, involvement in dangerous activities, self-inflated ego, grandiosity, or promiscuity. The 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 a previous rape, isolates, fearful to go outside, has missed several days of work, appetite decreased. She has somatic concerns with GI upset and headaches. The client denied any current binging/purging behaviors, denied withholding food from self, or engaging in anorexic behaviors. No self-mutilation behaviors.


A 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 diagnoses of GAD; confirm by further evaluation 5 Mild Anxiety 10 Moderate anxiety 15 Severe anxiety

MDQ screen negative

PCL-5 Screen 32


· 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


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


The client was raised by adoptive parents since age 6; from Russian orphanage. She has unknown siblings. She is single; has no children.

Employed at a local tanning bed salon

Education: High School Diploma

Denied current legal issues.



· 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 hisremission.uicide – unknown

· Family history of mental illness – unknown

· Hopelessness – no

· Gender – female

· Marital status – single

· White race

· Access to means

· Substance abuse – in remission


· 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, the risk of lethality increased under the context of drugs/alcohol.

No required SAFETY PLAN related to low risk


She is a 25 yo Russian female who looks her stated age. She is cooperative with the examiner. She is neatly groomed and clean and dressed appropriately. There is mild psychomotor restlessness. Her speech is clear, coherent, and normal in volume and tone, and has a strong cultural accent. Her thought process is ruminative. There is no evidence of looseness of association or flight of ideas. Her mood is anxious and mildly irritable, and her affect is 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.


The client is a 25 yo Russian female who presents with a history of treatment for PTSD, ADHD, and 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.



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



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 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 affect mental health, physical health, and sleep architecture.

3) Patient was educated about the therapy and services of the MHC including emergent care. A referral was sent via email to the therapy team for PET treatment.

4) Patient has emergency numbers: Emergency Services 911, the national Crisis Line 800-273-TALK, and the MHC Crisis Clinic. The patient was instructed to go to the nearest ER or call 911 if they become actively suicidal and/or homicidal.

5) Time allowed for questions and answers to be provided. Provided supportive listening. Patient appeared to understand the discussion and appears to have the 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

The patient is amenable to this plan and agrees to follow the treatment regimen as discussed



· Explain what pertinent information, generally, is required in documentation to support DSM-5-TR and Updated 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


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