Decoding CPTE & M Codes and ICD-10 Diagnosis Codes- Applying Medical Decision-Making Complexity in New Patient Encounters

Decoding CPTE & M Codes and ICD-10 Diagnosis Codes- Applying Medical Decision-Making Complexity in New Patient Encounters

The case presented is of a 22-year-old male presenting with complaints of depression and significant experience of stress about his schooling. Assessment findings revealed the symptoms of anxiety, rumination, depression, social anxiety, and physical manifestations of palpitations and sweating. These findings are suggestive of anxiety and depressive disorders.

Diagnostic coding presents a systematic and simplistic approach to identifying clinical diagnoses. The complexity approach to medical decision-making stratifies patients’ presentation based on the complexity of their clinical manifestations and the difficulty of establishing a definitive therapeutic option (Sulieman et al., 2020). This approach utilizes a specific criterion centered on the number of possible diagnoses, the amount of complexity of the necessary diagnostics, and the risk for complications. Per these criteria, the stratiform of straightforward, low complexity, moderate complexity, and high complexity has been identified as the various levels of complexity (Music, 2022). It has a score of 1 point on the diagnosis/management and amount and complexity of data reviewed sections, indicating that diagnosis and management options are established. The presentation also has a low level of risk for complications, morbidity, and mortality. As per this criterion, the client in the case presented has a low complexity presentation.

The low complexity stratiform is a subclass within the complex medical decision-making approach. It denotes a medical presentation in which the presenting problems, diagnostic procedures, and management options are limited. As evident in the case, the presenting problems were anxiety and depression. This presentation necessitated limited diagnostic tests and required limited therapeutic approaches. The client presented thus fits the low complexity criteria.

Per the ICD 10 diagnostic coding, the billable code for this condition is anxiety disorder ICD 10 code F41.9 with depression ICD 10 code F41.8. Notably, ICD 10 code sequencing during billing has an impact on third-party payer reimbursements. Consequently, correct coding allows third-party payers to reimburse providers for the actual care they provide to the patients. Inaccurate coding may result in claims of denial and rejections and may sometimes be surmounted to fraud (Arenchild et al., 2020). This is especially true when over-reimbursements are apparent. It is thus necessary that accurate codes be assigned to the presenting cases.

References

Arenchild, M., Offodile, A. C., & Revere, L. (2020). Do we get what we pay for? Examining the relationship between payments and clinical outcomes in high-volume elective surgery in a commercially insured population. INQUIRY: The Journal of Health Care Organization, Provision, and Financing, 57, 004695802096878. https://doi.org/10.1177/0046958020968780

Music, I. (2022). Medical decision making. Acta Informatica Medica, 30(3), 230. https://doi.org/10.5455/aim.2022.30.230-235

Sulieman, L., Robinson, J. R., & Jackson, G. P. (2020). Automating the classification of complexity of medical decision-making in patient-provider messaging in a patient portal. Journal of Surgical Research, 255, 224–232. https://doi.org/10.1016/

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Use your lecture materials to determine what CPT E&M Code and ICD-10 diagnosis code to utilize for this “new patient” encounter using the medical decision-making (complexity) approach.

Provide justification for the code you assigned by including the following information in your discussion:

This patient presents to a local health center. As the provider, you must conduct a full physical on the patient as well as a psychiatric intake.