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. Assign DSM-5-TR diagnoses and ICD-10 codes to the services documented in the case scenario. You will add your narrative answers to the assignment questions to the bottom of this template and submit them together as one document. | ||||||||||||||||||||||||||||||||||||||||
Identifying Information | Identification was verified by stating their name and date of birth. Time spent for evaluation: 1103am-1151am | ||||||||||||||||||||||||||||||||||||||||
Chief Complaint | “My primary doctor thinks I need more help than she can give me now.” | ||||||||||||||||||||||||||||||||||||||||
HPI | 42 young female was evaluated for psychiatric evaluation and referred by her primary care provider for worsening depression and panic symptoms. She is currently prescribed escitalopram 5mg po daily for depression, alprazolam 1mg po daily for anxiety. | ||||||||||||||||||||||||||||||||||||||||
Diagnostic Screening Results | Screen of symptoms in the past week: | ||||||||||||||||||||||||||||||||||||||||
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 | ||||||||||||||||||||||||||||||||||||||||
Psychosocial History | | Client was raised by single mother. She is married; has 2 children. Employed at local day care as administrative assistant. Education: High School Diploma Denied current legal issues. | |||||||||||||||||||||||||||||||||||||||
Suicide / Homicide Risk Assessment | | Suicide Inquiry: Denies active suicidal ideations, intentions, or plans. | |||||||||||||||||||||||||||||||||||||||
Mental Status Examination | | She is a 42 yo Hispanic female who looks her stated age. She is cooperative with examiner. She is disheveled, dressed appropriately. There is psychomotor restlessness. Her. Her mood is anxious and mildly irritable. She denies any auditory or visual hallucinations. There is no evidence of any delusional thinking. She denies any current suicidal or homicidal ideation. | |||||||||||||||||||||||||||||||||||||||
Clinical Impression | | The client is a 42 yo Hispanic female who presents with a history of treatment for depression and panic symptoms. Moods are anxious and irritable. She has reported symptoms related to her depression and panic. no evident mania/hypomania, no psychosis, 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. | |||||||||||||||||||||||||||||||||||||||
Diagnostic Impression | | [Student to provide DSM-5-TR diagnoses with ICD-10 coding] Double click inside this text box to add/edit text. Delete placeholder text when you add your answers. | |||||||||||||||||||||||||||||||||||||||
Treatment Plan | |
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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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