Psychiatric Case Scenario: Coding, Evaluation, and Management

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Please see attached Case Scenario

Under the Diagnostic Impression, review the assigned DSM-5 and ICD-10 codes to services based upon the patient case scenario to ensure accuracy.

In 2 pages address the following.

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

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

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

Thank you for reviewing this scenario and providing insight into coding and billing.

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