NRNP 6675 Week 2 E M Patient Case Study

NRNP 6675 Week 2 E M Patient Case Study

E M Patient Case Study

Explain what pertinent information, generally, is required in documentation to support DSM-5-TR and Updated ICD-10 coding.

The history of the presenting patient is used to inform the DSM-5-TR and Updated ICD-10 coding. As a result, it’s critical to record the patient’s mental disease symptoms, including their onset, course, frequency, and severity. Making sure that the client’s symptoms are not connected to a previous diagnosis is also essential. Also, other symptoms impacting the patient’s cognitive abilities and behavior must be documented during the mental status evaluation of the patient (Reed et al., 2019). The client’s history of drug use may also be useful in determining the related diseases’ diagnosis. To certify that a correct primary diagnosis is obtained using the aforementioned criteria, the patient’s presumptive diagnosis and comorbidities must be documented. Determining if the patient is a new client seeking therapy or has previously received care for her current mental condition from a different doctor is also crucial. Clients are regarded as new if they haven’t gotten care in at least three years. For accurate billing, a new patient must use the correct codes.

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Explain what pertinent documentation is missing from the case scenario, and what other information would be helpful to narrow your coding and billing options.

Some of the critical information that is lacking from the aforementioned case scenario is the frequency, causes, and mitigating variables of the patient’s daily symptoms. There is no compilation of likely diagnoses. Notwithstanding their significance in the diagnosis and classification of the client’s mental disease, several additional severity indications for the client’s symptoms are equally pertinent (Horsky et al., 2018). Moreover, physical issues like discomfort have been ruled out.

But, to limit the patient’s coding and billing possibilities, it is necessary to obtain as much patient data as can be obtained, including address, mail, place of work, and phone number, among other things. Throughout the coding and billing process, lab data must be reviewed, and imaging tests like as X-rays must be examined (First et al., 2018). Incorrect, duplicate, and missing data must be repaired. Collecting precise and thorough information aids in the avoidance of inaccurate codes, which lead to improper billing alternatives.

Finally, explain how to improve documentation to support coding and billing for maximum reimbursement.

According to the Medical Group Management Association, increasing a practice’s revenue requires precise paperwork that follows all reporting rules, as well as tracking down denials and filing appeals on time. The following six tactics can assist encourage maximum compensation from accurate coding and billing: designate one person as an internal claim tracker; use rejection as a teaching tool; involve medical professionals and other health professionals in coding; make use of updated coding resources and regulatory requirements; carefully review the clinician’s or physician’s records before coding; and, lastly, cooperate with a reliable medical assertions firm (Esposito et al., 2020).

References

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. https://doi.org/10.1136/tsaco-2020-000586

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. https://doi.org/10.1002/wps.20525

‌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. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5977598/.

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. https://doi.org/10.1002/wps.20611

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• 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.