The Pertinent Information Generally Required in Documentation to Support D.S.M. 5 and ICD-10

The Pertinent Information Generally Required in Documentation to Support D.S.M. 5 and ICD-10

Healthcare institutions use the D.S.M. 5 to make the appropriate diagnosis, which is then used to inform treatment approaches for patients with certain conditions. Furthermore, the criteria allow for a systematic approach to approaching needs. The D.S.M. 5 assigns specific codes to specific requirements, making it easier to diagnose the conditions (Castagnini & Fusar-Poli, 2017). The ICD-10, conversely, contains information about morbidity in specific patients and mortality trends for the condition.

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Insurance companies use ICD-10 codes to facilitate payment for specific services. The use of the codes, therefore, necessitates that important information about the patient is adequately captured: history of presenting complaint, duration of presentation, frequency, other associated conditions, and presence of the illness in the family (Amin et al., 2019). Treatment will be simple when the presenting diseases and their frequency are determined.

Relevant documentation is missing.

The patient’s diagnoses are listed in the case study. There is also a breakdown of the severity of the conditions, but no specific codes are assigned to them. Depression, attention deficit disorder, and stimulant use disorder were all observed in the patient. It is difficult to know when the patient has a mixed presentation of the conditions when there is insufficient information for the patient. Because the patient already has multiple states, it will be challenging to manage them properly if some information is missing. Other treatment approaches, such as cognitive-behavioral therapy, would need to be included in the patient’s treatment plan to equip the patient with the necessary skills to manage the recurrence of the conditions (Raj et al., 2019). The patient’s ailments have recurred, raising concerns about how the patient takes the medications. As a result, it would be critical to address any potential noncompliance by the patient to treat the conditions correctly.

How to Make Documentation Better

Incorporating technology into patient management is an essential approach to mental health conditions. In this regard, using electronic health records (E.H.R.) is an essential strategy. The technology is a critical approach for systematic documentation of patient conditions, making it simple to track presentations and, as a result, diagnose and treat patients. The therapist must provide specific presentations and procedures for the patient to bill the services.

To improve the documentation, it is critical to provide details about the patient’s presentation, including the severity and duration of the conditions. Other presenting conditions must also be detailed, which is part of the reimbursement process. Accurate codes for patient presentations are also required to ensure successful treatment. The evaluation and management of the patient should also be competitive. All patient presentations, including examinations, history, and decisions made about the patient, must be included by the healthcare provider. The caregiver should also specify the exact time the patient was attended to.

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References

Amin, S., Neumann, G., Dunfield, K., Vechkaeva, A., Chapman, K. A., & Wixted, M. K. (2019). MLT-DFKI at CLEF eHealth 2019: Multi-label Classification of ICD-10 Codes with BERT. In CLEF (Working Notes).

Castagnini, A. C., & Fusar-Poli, P. (2017). Diagnostic validity of ICD-10 acute and transient psychotic disorders and DSM-5 brief psychotic disorder. European Psychiatry, 45, 104- 113.

Raj, S., Sachdeva, S. A., Jha, R., Sharad, S., Singh, T., Arya, Y. K., & Verma, S. K. (2019). Effectiveness of mindfulness-based cognitive behavior therapy on life satisfaction and life orientation of adolescents with depression and suicidal ideation. Asian journal of psychiatry, 39, 58–62.

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Assign DSM-5-TR and ICD-10 codes to services based on 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 them together as one document.

The Pertinent Information Generally Required in Documentation to Support D.S.M. 5 and ICD-10

Explain what pertinent information 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.