EVALUATION AND MANAGEMENT (E/M) 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.
Pathways Mental Health
Psychiatric Patient Evaluation
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. | ||||||||||||||||||||||||||||||||||||||||
Diagnostic Screening Results | Screen of symptoms in the past 2 weeks: | ||||||||||||||||||||||||||||||||||||||||
Past Psychiatric and Substance Use Treatment |
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Substance Use History | Have you used/abused any of the following (include frequency/amt/last use):
Any history of substance related:
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:
PROTECTIVE FACTORS FOR SUICIDE:
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 | |
Patient is amenable with this plan and agrees to follow treatment regimen as discussed. | |||||||||||||||||||||||||||||||||||||||
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[In 1-2 pages, address the following:
Add your answers here. Delete instructions and placeholder text when you add your answers. |
References
[Add APA-formatted citations for any sources you referenced
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