NRNP 6675 WU Evaluation and Management Paper


Review this week’s Learning Resources on coding, billing, reimbursement.

Review the E/M patient case scenario provided.


  • Assign DSM-5-TR and ICD-10 codes to services based upon the patient case scenario. 

Then, in 1–2 pages address the following. You may add your narrative answers to these questions to the bottom of the case scenario document and submit 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, 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.   

Expert Solution Preview

In this assignment, we will be discussing the coding, billing, and reimbursement aspects of medical practice, specifically focusing on the DSM-5-TR and ICD-10 coding systems. We will analyze a patient case scenario and apply the appropriate codes to the services provided. Additionally, we will explore the importance of documentation in supporting accurate coding and billing and discuss ways to enhance documentation for maximum reimbursement.

Answer to Question 1:
Pertinent information required in documentation to support DSM-5-TR and ICD-10 coding includes detailed descriptions of the patient’s symptoms, clinical findings, diagnoses, and procedures performed. It is crucial to have clear and concise documentation that accurately represents the patient’s condition and the services provided. This information should be well-organized and readily accessible to ensure accurate code assignment and appropriate reimbursement.

Answer to Question 2:
Upon reviewing the case scenario, several pertinent documentation elements appear to be missing. First, there is limited information regarding the patient’s medical history, such as any pre-existing conditions or previous treatments. This information is vital for accurately coding and billing as it provides important context for the current condition. Additionally, there is a lack of documentation regarding the patient’s response to previous treatments, which would assist in determining the appropriate course of action and further narrowing the coding options.

Answer to Question 3:
To improve documentation to support coding and billing for maximum reimbursement, several strategies can be implemented. Firstly, it is crucial to ensure accurate and comprehensive documentation of all relevant patient details, including medical history, previous treatments, and response to interventions. This additional information allows for better code selection and helps to establish medical necessity for the provided services.

Secondly, healthcare providers should include thorough and detailed descriptions of the patient’s symptoms, clinical findings, and treatment procedures. Specificity is key in coding, as it enables the selection of more precise codes that best reflect the complexity and severity of the patient’s condition. Furthermore, documenting the time spent on each service and the level of medical decision-making involved can support appropriate coding and reimbursement.

Lastly, regular education and training sessions can be conducted to enhance healthcare providers’ awareness and understanding of coding requirements. This promotes consistency and accuracy in documentation, leading to improved coding and billing practices.

By implementing these strategies, healthcare professionals can optimize documentation to support DSM-5-TR and ICD-10 coding, ensuring accurate billing and maximum reimbursement.

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