Evaluation and Management (E.M)

NARRATIVE ANSWERS

Pertinent Information to Support DSM-5 and ICD-10 coding

The DSM-5 is a document that specifies the criteria to establish the diagnoses of practically all types of psychiatric health disorders currently accepted by the medical sector. When an individual visits their primary psychiatric practitioner, they get examined using those criteria. When a client meets the criteria for a specific psychiatric health illness, the diagnosis is linked to their health issue. As useful as the paper is, its application is limited to equally and billing. Therefore, the ICD-10 document was developed. The ICD-10 changes an accepted diagnosis into diagnosis that is internationally accepted code that can be used in billing, allowing the healthcare providers to be compensated according for their services (Mainor et al., 2019). There may be some further information required to finish this process. This includes the patient's health record for which the diagnosis coding was given. When examining the patient, the healthcare provider must obtain a complete history, write the results of a comprehensive physical exam, and explain the laboratory results. To obtain the right diagnosis, investigations must be carried out in accordance with the diagnostic criteria. This record is then used to support the diagnostic and billing code.

Pertinent Documentation that is missing from the Case Scenario

The healthcare professional can include specifiers in the DSM-5/ICD-10 coding to even more restrict the diagnosis (First et al., 2021). In addition, the clinician may incorporate other aspects in the patient's initial symptoms that explain better the overall situation of the presenting indicators and symptoms that lead to the primary diagnosis. In this case study,

the details of the patient regarding any diagnosed disorders in the past such as ADHD and PTSD are not clarified in full. This is especially true for the symptoms that resented initially. This could give information on if the diseases are mild or severe, and whether there was been enough changes to suggest a status of improvement. There is also an opportunity to state the number of incidents experienced, which helps to further define the primary diagnosis. As a result, symptoms that have not been classified to validate the diagnosis could be recorded individually so that they can be shown when further evidence is available. Details of the indicated diagnosis might also have been given as additional information. There are few symptoms described in the clinical assessment for generalized anxiety disorder, and the little follow-up is minimal to determine if the symptoms have managed.

Improving Documentation to Support Coding and Billing for Maximum Reimbursement

According to a number of research studies, few practitioners use coding and billing systems unless they definitely have to. Furthermore, those who might use the system may not use it correctly. There are several suggestions for improving documentation in order to promote coding and billing for ultimate reimbursement. Some of the techniques include bringing healthcare practitioners together by giving proper education on coding and billing so the documentation can improve. A diverse approach proved to be the most fruitful method. This might include things like making paperwork easier, tracking feedback through regular audits, and employing reminders and templates. To enhance efficient and accurate capture of patient information, the healthcare institution should also employ current technology such as Electronic Health Records (EHR) (Vos et al., 2020). Clinicians will find it much easier to record and update patient information using the EHR system. Since insurance companies have obligations to honor contracts to participants, they demand stability and trustworthy documentation, which can be easily obtained through EHR.