NRNP 6675 WU Evaluation and Management Paper

TO PREPARE

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

Review the E/M patient case scenario provided.

THE ASSIGNMENT

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.

Student Name
College of Nursing-PMHNP, Walden University
NRNP 6675: PMHNP Care Across the Lifespan II
Faculty Name
Assignment Due Date
WALDEN UNIVERSITY, LLC
Pathways Mental Health
PSYCHIATRIC PATIENT EVALUATION
INSTRUCTIONS
Use the following case template to complete Week 2 Assignment 1. On page 5, assign DSM-5TR and Updated ICD-10 codes to the services documented. You will add your narrative
answers to the assignment questions to the bottom of this template and submit altogether as
one document.
IDENTIFYING
INFORMATION
Identification was verified by stating of their name and date of birth.
CHIEF COMPLAINT
HPI
Time spent for evaluation: 0900am-0957am
“My other provider retired. I don’t think I’m doing so well.”
25 yo Russian female evaluated for psychiatric evaluation referred from her retiring practitioner
for PTSD, ADHD, Stimulant Use Disorder, in remission. She is currently prescribed fluoxetine
20mg po daily for PTSD, atomoxetine 80mg po daily for ADHD.
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, selfinflated 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
Screen of symptoms in the past 2 weeks:
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
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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
•
•
•
•
•
SUBSTANCE USE
HISTORY
Entered mental health system when she was age 19 after raped by a stranger during a
house burglary.
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
Have you used/abused any of the following (include frequency/amt/last use):
Substance
Tobacco products
ETOH
Y/N
Y
Y
Cannabis
Cocaine
Prescription stimulants
Methamphetamine
Inhalants
Sedative/sleeping pills
Hallucinogens
Street Opioids
Prescription opioids
Other: specify (spice, K2, bath salts,
etc.)
N
Y
Y
N
N
N
N
N
N
Y
Frequency/Last Use
½
last drink 2 weeks ago, reports drinks
1-2 times monthly one drink socially
last use 2015
last use 2015
reports one-time ecstasy use in 2015
Any history of substance related:
•
•
•
•
•
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Blackouts: +
Tremors: DUI: D/T’s: Seizures: Walden University, LLC rev 6.2022
Longest sobriety reported since 2015—stayed sober maintaining sponsor, sober friends, and
meetings
PSYCHOSOCIAL
HISTORY
SUICIDE / HOMICIDE
RISK ASSESSMENT
Client was raised by adoptive parents since age 6; from Russian orphanage. She has unknown
siblings. She is single; has no children.
Employed at local tanning bed salon
Education: High School Diploma
Denied current legal issues.
RISK FACTORS FOR SUICIDE:
• 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
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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
She is a 25 yo Russian female who looks her stated age. She is cooperative with examiner. She is
neatly groomed and clean, dressed appropriately. There is mild psychomotor restlessness. Her
speech is clear, coherent, normal in volume and tone, has strong cultural accent. Her thought
process is ruminative. There is no evidence of looseness of association or flight of ideas. Her
mood is anxious, mildly irritable, and her affect appropriate to her mood. She was smiling at
times in an appropriate manner. She denies any auditory or visual hallucinations. There is no
evidence of any delusional thinking. She denies any current suicidal or homicidal ideation.
Cognitively, She is alert and oriented to all spheres. Her recent and remote memory is intact. Her
concentration is fair. Her insight is good.
Client is a 25 yo Russian female who presents with history of treatment for PTSD, ADHD,
Stimulant use Disorder, in remission.
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-TR AND UPDATED ICD-10 CODING]
Double click inside this text box to add/edit text. Delete placeholder text when you add your
answers.
TREATMENT PLAN
1) Medication:
• 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.
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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 800-273TALK, 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.
NARRATIVE ANSWERS
[IN 1-2 PAGES, ADDRESS THE FOLLOWING:
•
Explain what pertinent information, generally, is required in documentation to support DSM-5-TR and
Updated 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.]
Add your answers here. Delete instructions and placeholder text when you add your answers.
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REFERENCES
[ADD APA-FORMATTED CITATIONS FOR ANY SOURCES YOU REFERENCED
Delete instructions and placeholder text when you add your citations.
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