25 yo Russian female evaluated for psychiatric evaluation referred from her retiring practitioner for PTSD, ADHD, Stimulant Use Disorder, in remission.

QUESTION

Pathways Mental Health

Psychiatric Patient Evaluation

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Instructions

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.

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

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

Psychosocial History

Client was raised by adoptive parents since age 6; from Russian orphanage. She has unknown siblings. She is single; has no children. Employed at local tanning bed salon Education: High School Diploma Denied current legal issues.

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

Mental Status Examination

She is a 25 yo Russian female who looks her stated age. She is cooperative with examiner. She is neatly groomed and clean, dressed appropriately. There is mild psychomotor restlessness. 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

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-TR and Updated ICD-10 coding] Double click inside this text box to add/edit text. Delete placeholder text when you add your answers.

Treatment Plan

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 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. Patient was educated about therapy and services of the MHC including emergent care. Referral was sent via email to therapy team for PET treatment. 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. 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. RTC in 30 days 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.

Narrative Answers

[In 1-2 pages, address the following:

· 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 reimbursement.]

ANSWER

Optimizing Documentation for DSM-5-TR and ICD-10 Coding and Billing: A Case Study Analysis

Pertinent information is required in documentation to support DSM-5-TR and Updated ICD-10 coding. This includes detailed information about the patient’s presenting symptoms, history, mental status examination, and diagnostic assessments. The documentation should provide a comprehensive picture of the patient’s condition, including the duration, frequency, and severity of symptoms, as well as any impairments in functioning (Substance Abuse and Mental Health Services Administration (US), 2016). It should also include information about the patient’s past psychiatric and substance use treatment, including previous hospitalizations, medication trials, and diagnoses. Substance use history, psychosocial history, and suicide/homicide risk assessment are also important components to be documented.

In the given case scenario, there are several pieces of pertinent documentation missing. While it mentions the client’s current psychiatric diagnoses of PTSD, ADHD, and Stimulant Use Disorder in remission, it does not specify the diagnostic criteria used to arrive at these diagnoses. It would be helpful to have more information on the specific symptoms and impairments experienced by the client related to each diagnosis (Srinath et al., 2019). Additionally, there is no documentation of the client’s trauma history or the specific traumatic events that led to the diagnosis of PTSD. Including this information would provide a clearer understanding of the client’s condition.

To support coding and billing for maximum reimbursement, it is important to provide detailed and specific documentation. This includes documenting the time spent on evaluation and the duration of the appointment. The documentation should clearly link the reported symptoms to the relevant DSM-5-TR diagnostic criteria and provide evidence to support each diagnosis. It is also important to document the functional impairments experienced by the client, as well as the treatment plan, including medication adjustments and referrals for therapy. Including information about the client’s response to previous treatments and the rationale for the current treatment plan would further support the coding and billing process.

Improving documentation to support coding and billing for maximum reimbursement requires a comprehensive and thorough approach. It is important to include all relevant information related to the patient’s symptoms, history, assessments, and treatment plan. The documentation should be clear, concise, and specific, avoiding vague or ambiguous language. It should provide sufficient detail to justify the selected diagnostic codes and treatment interventions (Lorenzetti et al., 2018). Regularly updating and reviewing the documentation to reflect changes in the patient’s condition and treatment progress is also essential.

In summary, pertinent information is required in documentation to support DSM-5-TR and Updated ICD-10 coding. In the given case scenario, additional information about the diagnostic criteria, trauma history, and specific symptoms would be helpful to narrow coding and billing options. To improve documentation for maximum reimbursement, it is important to provide detailed and specific information, justify the selected codes and treatment interventions, and regularly update the documentation to reflect patient condition changes.

References

Lorenzetti, D. L., Quan, H., Lucyk, K., Cunningham, C. T., Hennessy, D., Jiang, J. Z., & Beck, C. A. (2018). Strategies for improving physician documentation in the emergency department: a systematic review. BMC Emergency Medicine, 18(1). https://doi.org/10.1186/s12873-018-0188-z 

Substance Abuse and Mental Health Services Administration (US). (2016, June 1). DSM-5 Child Mental Disorder Classification. DSM-5 Changes – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK519712/ 

Srinath, S., Jacob, P., Sharma, E., & Gautam, A. (2019). Clinical practice guidelines for assessment of children and adolescents. Indian Journal of Psychiatry, 61(8), 158. https://doi.org/10.4103/psychiatry.indianjpsychiatry_580_18 

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