Instructions

Identifying Information

Time spent for evaluation: 0900am-0957am

Chief Complaint

HPI

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Assignment 1: Week 2 Evaluation and Management

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Today, client denied symptoms of depression, denied anergia, anhedonia, amotivation, no anxiety, denied frequent worry, reports feeling restlessness, no reported panic symptoms, no reported obsessive/compulsive behaviors. Client denies active SI/HI ideations, plans or intent. There is no evidence of psychosis or delusional thinking.  Client denied past episodes of hypomania, hyperactivity, erratic/excessive spending, involvement in dangerous activities, self-inflated ego, grandiosity, or promiscuity. Client reports increased irritability and easily frustrated, loses things easily, makes mistakes, hard time focusing and concentrating, affecting her job. Has low frustration tolerance, sleeping 5–6 hrs/24hrs reports nightmares of previous rape, isolates, fearful to go outside, has missed several days of work, appetite decreased. She has somatic concerns with GI upset and headaches. Client denied any current binging/purging behaviors, denied withholding food from self or engaging in anorexic behaviors. No self-mutilation behaviors.

Diagnostic Screening Results

PHQ 9= 0 with symptoms rated as no difficulty in functioning
Interpretation of Total Score
Total Score Depression Severity 1-4 Minimal depression 5-9 Mild depression 10-14 Moderate depression 15-19 Moderately severe depression 20-27 Severe depression

GAD 7= 2 with symptoms rated as no difficulty in functioning
Interpreting the Total Score:
Total Score Interpretation ≥10 Possible diagnosis of GAD; confirm by further evaluation 5 Mild Anxiety 10 Moderate anxiety 15 Severe anxiety

MDQ screen negative

PCL-5 Screen 32

Past Psychiatric and Substance Use Treatment

·         Previous Psychiatric Hospitalizations:  denied

·         Previous Detox/Residential treatments: one for abuse of stimulants and cocaine in 2015

·         Previous psychotropic medication trials: sertraline (became suicidal), trazodone (worsened nightmares), bupropion (became suicidal), Adderall (began abusing)

·         Previous mental health diagnosis per client/medical record: GAD, Unspecified Trauma, PTSD, Stimulant use disorder, ADHD confirmed by school records

Substance Use History

Have you used/abused any of the following (include frequency/amt/last use):

Any history of substance related:

·         Blackouts:  +

·         Tremors:   –

·         DUI: –

·         D/T’s: –

·         Seizures: –

Longest sobriety reported since 2015—stayed sober maintaining sponsor, sober friends, and meetings

Psychosocial History

Employed at local tanning bed salon

Education: High School Diploma

Denied current legal issues.

Suicide / HOmicide Risk Assessment

·         Suicidal Ideas or plans – no

·         Suicide gestures in past – no

·         Psychiatric diagnosis – yes

·         Physical Illness (chronic, medical) – no

·         Childhood trauma – yes

·         Cognition not intact – no

·         Support system – yes

·         Unemployment – no

·         Stressful life events – yes

·         Physical abuse – yes

·         Sexual abuse – yes

·         Family history of suicide – unknown

·         Family history of mental illness – unknown

·         Hopelessness – no

·         Gender – female

·         Marital status – single

·         White race

·         Access to means

·         Substance abuse – in remission

PROTECTIVE FACTORS FOR SUICIDE:

·         Absence of psychosis – yes

·         Access to adequate health care – yes

·         Advice & help seeking – yes

·         Resourcefulness/Survival skills – yes

·         Children – no

·         Sense of responsibility – yes

·         Pregnancy – no; last menses one week ago, has Norplant

·         Spirituality – yes

·         Life satisfaction – “fair amount”

·         Positive coping skills – yes

·         Positive social support – yes

·         Positive therapeutic relationship – yes

·         Future oriented – yes

Suicide Inquiry: Denies active suicidal ideations, intentions, or plans. Denies recent self-harm behavior. Talks futuristically. Denied history of suicidal/homicidal ideation/gestures; denied history of self-mutilation behaviors

Global Suicide Risk Assessment: The client is found to be at low risk of suicide or violence, however, risk of lethality increased under context of drugs/alcohol.

No required SAFETY PLAN related to low risk

Mental Status Examination

Clinical Impression

Moods are anxious and irritable. She has ongoing reported symptoms of re-experiencing, avoidance, and hyperarousal of her past trauma experiences; ongoing subsyndromal symptoms related to her past ADHD diagnosis and exacerbated by her PTSD diagnosis. She denied vegetative symptoms of depression, no evident mania/hypomania, no psychosis, denied anxiety symptoms. 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. She is a low risk for self-harm based on her current clinical presentation and her risk and protective factors.

Diagnostic Impression

[Student to provide DSM-5 and ICD-10 coding]

i.            Posttraumatic Stress Disorder (PTSD) DSM-5 309.81; ICD-10: F43. 10

ii.            Attention-Deficit Hyperactivity Disorder DSM-5 314.01; ICD-10: F90. 0

Treatment Plan

·         Increase fluoxetine 40mg po daily for PTSD #30 1 RF

·         Continue with atomoxetine 80mg po daily for ADHD.  #30 1 RF

Instructed to call and report any adverse reactions.

Future Plan: monitor for decrease re-experiencing, hyperarousal, and avoidance symptoms; monitor for improved concentration, less mistakes, less forgetful

2)       Education: Risks and benefits of medications are discussed including non-treatment. Potential side effects of medications discussed. Verbal informed consent obtained.

Not to drive or operate dangerous machinery if feeling sedated.

Not to stop medication abruptly without discussing with providers.

Discussed risks of mixing  medications with OTC drugs, herbal, alcohol/illegal drugs. Instructed to avoid this practice. Praised and Encouraged ongoing abstinence. Maintain support system, sponsors, and meetings.

Discussed how drugs/ETOH affects mental health, physical health, sleep architecture.

3)       Patient was educated about therapy and services of the MHC including emergent care. Referral was sent via email to therapy team for PET treatment.

4)       Patient has emergency numbers: Emergency Services 911, the national Crisis Line 800-273-TALK, the MHC Crisis Clinic. Patient was instructed to go to nearest ER or call 911 if they become actively suicidal and/or homicidal.

5)       Time allowed for questions and answers provided. Provided supportive listening. Patient appeared to understand discussion and appears to have capacity for decision making via verbal conversation.

6)       RTC in 30 days

7)       Follow up with PCP for GI upset and headaches, reviewed PCP history and physical dated one week ago and include lab results

Patient is amenable with this plan and agrees to follow treatment regimen as discussed.

[In 1-2 pages, address the following:

·         Explain what pertinent information, generally, is required in documentation to support DSM-5 and ICD-10 coding.

The documentation needed to support DSM V coding includes diagnostic features, associated features supporting the diagnosis, clinical subtypes, risk, diagnostic measures, prognostic factors, and functional consequences. In addition, differential diagnosis, culture-related diagnostic issues, gender-related diagnostic issues, and recording procedures are needed in documentation (Regier & Narrow, 2018). The ICD-10 has codes for clinical symptoms, abnormal physical and diagnostic findings, diagnosis, social circumstances, and external causes of injury and disease. Therefore, the pertinent information needed in documentation to support ICD-10 coding includes the disease or injury cause, anatomical site, signs and symptoms, type, and severity of the injury or disease (Regier & Narrow, 2018).

·         Explain what pertinent documentation is missing from the case scenario, and what other information would be helpful to narrow your coding and billing options.

Pertinent documentation omitted in the case scenario includes the severity of symptoms, the patient’s comorbidities, and the primary and differential diagnoses with their ICD-10 and DSM V codes. Details about the patient, practitioner, and the clinic visit would help confine the coding and billing options. The patient details include the name, date of birth, the onset of the clinical symptoms, and insurance details. The practitioner’s details should include the name, address, signature, and the National Provider Identifier (NPI) number. Lastly, the details of the clinic visit should include the date and time of the visit, diagnosis codes, procedure codes, code modifiers, the quantity of items used in assessing, diagnosing, and treatment, and authorization information.

·         Finally, explain how to improve documentation to support coding and billing for maximum reimbursement.]

Documentation is key in coding and billing processes to ensure maximum reimbursement for healthcare providers and organizations. Providers can improve documentation by avoiding using EHR shortcuts which create obstacles in documenting a patient’s continuous inpatient status. Providers should document specific details about a procedure, such as the surgical approach used, each procedure performed during the operation, and unexpected events that occurred during the surgical procedure (Jaqua et al., 2020). In addition, healthcare providers should document evaluation and management in full to support coding and billing (Jaqua et al., 2020). Furthermore, providers can improve documentation by meeting or exceeding each history, physical examination, and medical decision-making element for the service level they choose in the following patient encounters: new patient visits, emergency services, consultations, and follow-up services. Organizations can adopt a Clinical documentation improvement (CDI) program, which improves the collection of medical data to maximize claims reimbursement revenue and improve quality of care (Rodenberg et al., 2019). Organizations can implement the CDI program by carrying out a gap analysis to identify issues in documentation in areas such as patient population, patient safety indicators, the severity of disease, risk of mortality, hospital-acquired infections, and rates of claim denial.