Reimbursement and the appropriate coding to support it are of paramount importance to the business side of the medical field. When a service is provided, a code is used to extract billable information from the medical documentation, which results in insurance reimbursements to the provider. Reimbursement rates and medical coding can be almost as complicated as treating some mental illnesses, and you will need to understand how to accurately code services for documentation, billing, and reimbursement.
This week, you analyze the relationships among documentation, coding, and billing in advanced practice nursing as you practice applying diagnostic criteria and service codes to a case study.
Apply DSM-5-TR diagnosis criteria and ICD-10 codes to patient service documentation
Analyze the relationships among documentation, coding, and billing in advanced practice nursing
Assessment 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 Assessment and management (E/M) documentation for a patient and perform a crosswalk of codes from DSM-5-TR to ICD-10.
• Review this week’s Learning Resources on coding, billing, reimbursement.
• Review the E/M patient case scenario provided.
ASSIGNMENT 1
• 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.
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Reimbursement and the appropriate coding to support it are of paramount importance to the business side of the medical field. When a service is provided, a code is used to extract billable information from the medical documentation, which results in insurance reimbursements to the provider. Reimbursement rates and medical coding can be almost as complicated as treating some mental illnesses, and you will need to understand how to accurately code services for documentation, billing, and reimbursement.
This week, you analyze the relationships among documentation, coding, and billing in advanced practice nursing as you practice applying diagnostic criteria and service codes to a case study.
Apply DSM-5-TR diagnosis criteria and ICD-10 codes to patient service documentation
Analyze the relationships among documentation, coding, and billing in advanced practice nursing
Assessment 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 Assessment and management (E/M) documentation for a patient and perform a crosswalk of codes from DSM-5-TR to ICD-10.
· Review this week’s Learning Resources on coding, billing, reimbursement.
· Review the E/M patient case scenario provided.
ASSIGNMENT 1
· 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.
Reading Resources
· American Psychiatric Association. (2022). ICD-10-CM Codes UpdateLinks to an external site. . 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 DiagnosesLinks to an external site. . https://www.psychiatry.org/psychiatrists/practice/dsm/updates-to-dsm/coding-updates
· American Psychiatric Association. (2020). Updates to DSM–5 criteria, text and ICD-10 codes Links to an external site. . https://www.psychiatry.org/psychiatrists/practice/dsm/updates-to-dsm-5
· American Psychiatric Association. (2013). Insurance implications of DSM-5Links to an external site. . 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 Links to an external site. . 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 disordersLinks to an external site. (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 Links to an external site. . 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 Links to an external site. . 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”
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Position Description: The Psychiatric/Mental Health (PMH) Registered Nurse, requires a wide range of nursing, psychosocial, and neurobiological expertise. PMH nurses promote well-being through prevention and education, in addition to the assessment, diagnosis, and treatment of mental health and substance use disorders. The nurse demonstrates ability to make clinical judgments in an effective and efficient manner and demonstrates critical thinking and performance ability in the coordination of patient care. The PMH RN works in a variety of settings and provides comprehensive care to individuals, families, and communities when applicable. Essential Duties and Responsibilities: Utilizes the nursing process to assess, plan, implement and evaluate patient care in a psychiatric facility setting Partners with individuals to achieve their recovery goals Provides health promotion and maintenance Conducts intake screening, Assessment, and triage Provides case management Teaches self-care activities Administers and monitors psychobiological treatment regimens Practices crisis intervention and stabilization Engages in psychiatric rehabilitation and intervention Educates patients, families, and communities Coordinates care within interdisciplinary teams Evaluates signs and symptoms indicating physiologic and psychosocial changes in the patient’s condition Identifies and prioritizes actions based upon patient care requirements Provides a safe, comfortable and therapeutic patient environment Revises the plan of care according to Assessment, changes in psychiatric and medical plan of care, and effective/ineffective nursing interventions Has strong awareness and understanding of suicide prevention Understands community resources and outpatient programs for mental health and substance use disorders Adheres to Facility/Client procedures and protocols at all times Performs other duties as assigned/necessary
Minimum Requirements: Current Registered Nurse Licensure in-state practicing Complies with all relevant professional standards of practice Participation and completion of Maxim’s Competency program when applicable Current CPR if applicable TB Questionnaire, PPD or chest x-ray if applicable Current Health certificate (per contract or state regulation) Must meet all federal, state and local requirements Successful completion of new hire training as applicable to job site Understand patient confidentiality and HIPAA requirements Ability to effectively elicit/provide information to and from appropriate individuals (including, but not limited to, supervisors, co-workers, clients) via strong communication skills; proficiency in the English language is required Computer proficiency required Must be at least 18 years of age Compliance & Ethics Expectations: Participates and successfully completes the Company’s Compliance program requirements and adheres to the Code of Conduct, Company policies, and applicable federal and state requirements Sets an example for other employees regarding how the Company’s Code of Conduct and Compliance Program
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Pertinent Information Required in Documentation for DSM-5-TR and ICD-10 Coding
The pertinent information required in documentation for DSM-5-TR and ICD-10 coding includes:
Chief complaint: A brief statement of the patient’s reason for seeking treatment.
History of present illness: A detailed description of the patient’s symptoms, including their onset, duration, severity, and associated factors.
Past medical history: A review of the patient’s past medical conditions, surgeries, and hospitalizations.
Social history: Information about the patient’s family, employment, education, and social activities.
Mental status examination: A comprehensive assessment of the patient’s mental state, including their appearance, mood, affect, thought process, and level of consciousness.
Physical examination: A comprehensive assessment of the patient’s physical health, including their vital signs, body systems, and neurological status.
Pertinent Documentation Missing from the Case Scenario
The case scenario is missing the following pertinent documentation:
Chief complaint: The chief complaint is not stated in the case scenario. This is important information because it helps the provider to determine the appropriate diagnostic testing and treatment.
History of present illness: The history of present illness is not detailed in the case scenario. This information is important because it helps the provider to understand the patient’s symptoms and how they have been impacting their life.
Past medical history: The past medical history is not included in the case scenario. This information is important because it helps the provider to identify any underlying medical conditions that may be contributing to the patient’s symptoms.
Social history: The social history is not included in the case scenario. This information is important because it helps the provider to understand the patient’s support system and any stressors in their life that may be contributing to their symptoms.
Mental status examination: The mental status examination is not included in the case scenario. This information is important because it helps the provider to assess the patient’s mental state and identify any cognitive or behavioral problems.
Physical examination: The physical examination is not included in the case scenario. This information is important because it helps the provider to rule out any physical causes for the patient’s symptoms.
How to Improve Documentation to Support Coding and Billing for Maximum Reimbursement
To improve documentation to support coding and billing for maximum reimbursement, providers should:
Be as specific as possible when describing the patient’s symptoms. The more specific the provider is, the easier it will be for the coder to assign the correct codes.
Include all relevant information in the documentation. This includes the chief complaint, history of present illness, past medical history, social history, mental status examination, and physical examination.
Use proper terminology. The provider should use the correct medical terminology when describing the patient’s symptoms and diagnosis.
Sign and date the documentation. The provider should sign and date all documentation to ensure that it is accurate and complete.
