Explain what pertinent information, generally, is required in documentation

 A​‌‍‍‍‌‍‌‍‍‍‌‌‌‍‌‌‌‌‌‌​ssignment 1: 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. The payer then reimburses the service at a certain rate. As a provider, you will have to understand what codes to use and what documentation is necessary to support coding.
--For this Assignment, you will review evaluation and management (E/M) documentation for a patient and perform a crosswalk of codes from DSM-5-TR to ICD-10.
***** TO PREPARE:
-Review this week’s Learning Resources on coding, billing, reimbursement.
-Review the E/M patient case scenario provided. (FILE ATTACHED)
****The Assignment
Assign DSM-5-TR and ICD-10 codes to services based upon the patient case scenario (CASE SCENARIO FILE ATTACHED).
******Then, in 2 pages address the following. You may add your narrative answers to these questions to the bottom of the case scenario document and submit them 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 (case scenario file attached), 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.
Learning Resources for NRNP 6675: PMHNP Care Across the Lifespan II Class
Required Readings (click to expand/reduce)
American Psychiatric Association. (2022). ICD-10-CM Codes Update. https://www.psychiatry.org/psychiatrists/practice/dsm/updates-to-dsm/updates-to-dsm-5-tr-criteria-text
American Psychiatric Association. (2022). Changes to ICD-10-CM Codes for DSM-5 Diagnoses. https://www.psychiatry.org/psychiatris​‌‍‍‍‌‍‌‍‍‍‌‌‌‍‌‌‌‌‌‌​ts/practice/dsm/updates-to-dsm/coding-updates
American Psychiatric Association. (2020). Updates to DSM–5 criteria, text and ICD-10 codes. https://www.psychiatry.org/psychiatrists/practice/dsm/updates-to-dsm-5
American Psychiatric Association. (2013). Insurance implications of DSM-5. https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM_Insurance-Implications-of-DSM-5.pdf
Clicking on this link will initiate the download of the PDF.
American Psychiatric Association. (2020). Coding and reimbursement.
https://www.psychiatry.org/psychiatrists/practice/practice-management/coding-reimbursement-medicare-and-medicaid/coding-and-reimbursement
American Psychiatric Association. (2022). Numerical listing of DSM-5 diagnoses and codes (ICD-10-CM). In Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://go.openathens.net/redirector/waldenu.edu?url=https://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425787
Buppert, C. (2021). Nurse practitioner's business practice and legal guide (7th ed.). Jones & Bartlett Learning.
Chapter 9, “Reimbursement for Nurse Practitioner Services”
Centers for Medicare & Medicaid Services. (2020). Your billing responsibilities. https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/ProviderServices/Your-Billing-Responsibilities
Stewart, J. G., & DeNisco, S. M. (2019). Role development for the nurse practitioner (2nd ed.). Jones & Bartlett Learning.
Chapter 15, “Reimbursement for Nurse Practitioner Services”
Walden University Academic Skills Center. (2017). Developing SMART goals. https://academicguides.waldenu.edu/ld.php?content_id=51901492
Zakhari, R. (2021). The psychiatric-mental health nurse practitioner certification review manual. Springer Publishing Company.
Chapter 4 “Neuroanatomy, Physiology, and ​‌‍‍‍‌‍‌‍‍‍‌‌‌‍‌‌‌‌‌‌​Mental Illness”