NARRATIVE ANSWERS
Pertinent Information in Documenting ICD-10 and DSM-5 Coding
For the documentation of reliable ICD-10 and DSM-V coding, certain information is needed. Missing information can lead to poor quality of care and underpayment of the offered services by the insurance scheme or payer. Some of the crucial information contained in ICD-10 and DSM coding include patient history, physical examination, medical decision making, patient counseling, care coordination, nature of the presenting medical condition, and time (Mandia, 2020). The above components are broken down further into specifics. For instance, comprehensive patient history entails information like the chief complaint, history of presenting illness, review of the system, and relevant family and social history among others (Sarmiento & Lau, 2020). In the provided case study of a 25-year-old Russian female patient, some of this information has been captured including the time that was spent in the provision of care services to the patient. The patient history of presenting illness has also been illustrated comprehensively. Additional necessary information for the documentation of the above case study includes suicide risk assessment, substance use history, mental status examination, and care plan among others. Missing Pertinent information in the Case Study
However, some pertinent information is missing in the provided case study, which is crucial in promoting accurate ICD-10 and DSM-V coding and classification. For instance, the identifying information only mentions the time that was spent with the patient leaving out the particular date that the patient was attended to (First et al., 2018). This is important in promoting appropriate follow-up and monitoring the care outcome for the implementation of appropriate interventions. NARRATIVE ANSWERS Pertinent Information in Documenting ICD-10 and DSM-5 Coding For the documentation of reliable ICD-10 and DSM-V coding, certain information is needed. Missing information can lead to poor quality of care and underpayment of the offered services by the insurance scheme or payer. Some of the crucial information contained in ICD-10 and DSM coding include patient history, physical examination, medical decision making, patient counseling, care coordination, nature of the presenting medical condition, and time (Mandia, 2020). The above components are broken down further into specifics. For instance, comprehensive patient history entails information like the chief complaint, history of presenting illness, review of the system, and relevant family and social history among others (Sarmiento & Lau, 2020). In the provided case study of a 25-year-old Russian female patient, some of this information has been captured including the time that was spent in the provision of care services to the patient. The patient history of presenting illness has also been illustrated comprehensively. Additional necessary information for the documentation of the above case study includes suicide risk assessment, substance use history, mental status examination, and care plan among others. Missing Pertinent information in the Case Study However, some pertinent information is missing in the provided case study, which is crucial in promoting accurate ICD-10 and DSM-V coding and classification. For instance, the identifying information only mentions the time that was spent with the patient leaving out the particular date that the patient was attended to (First et al., 2018). This is important in promoting appropriate follow-up and monitoring the care outcome for the implementation of appropriate interventions. Page | 5 Walden University, LLC This study source was downloaded by 100000821048274 from CourseHero.com on 06-07-2023 20:09:17 GMT -05:00 https://www.coursehero.com/file/182091213/Week-2-Assignment-1-Evaluation-and-Management-E-Mdocx/ The identifying information of both the retiring practitioner and the attending medical practitioner is also missing. This information is useful especially when inquiries or clarifications are needed regarding the history of drug use among other factors. Improving Documentation in Support of Billing and Coding for Maximum Reimbursement To promote maximum reimbursements, the healthcare organization should adopt modern technology such as Electronic Health Records (EHR) to promote efficient and accurate documentation of patient information (Bajowala et al., 2020). Clinicians will find it quite easier to use the EHR system to record and update patient information. Given that insurance schemes among other payers have a contractual obligation with the enrollees, they require consistent and reliable documentation which can easily be attained through EHR. In case of a claim, additional information may be required including the justification for the care services offered. As such, the adoption of good documentation practice will guarantee patients a maximum reimbursement of the provided care services.Management-E-Mdocx/ The identifying information of both the retiring practitioner and the attending medical practitioner is also missing. This information is useful especially when inquiries or clarifications are needed regarding the history of drug use among other factors.
Improving Documentation in Support of Billing and Coding for Maximum Reimbursement To promote maximum reimbursements, the healthcare organization should adopt modern technology such as Electronic Health Records (EHR) to promote efficient and accurate documentation of patient information (Bajowala et al., 2020). Clinicians will find it quite easier to use the EHR system to record and update patient information. Given that insurance schemes among other payers have a contractual obligation with the enrollees, they require consistent and reliable documentation which can easily be attained through EHR. In case of a claim, additional information may be required including the justification for the care services offered. As such, the adoption of good documentation practice will guarantee patients maximum reimbursement of the provided care services.
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