EVALUATION AND MANAGEMENT (E/M)
Insurance coding and billing is complex, but it boils down to how to accurately apply a code, or CPT (current procedural terminology), to the service that you provided. The payer then reimburses the service at a certain rate. As a provider, you will have to understand what codes to use and what documentation is necessary to support coding.(DSM-5 and ICD-10 coding Documentation Comprehensive Nursing Essay)
For this Assignment, you will review evaluation and management (E/M) documentation for a patient and perform a crosswalk of codes fromDSM-5-TR to ICD-10.
RESOURCES
Be sure to review the Learning Resources before completing this activity. Click the weekly resources link to access the resources.
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.(DSM-5 and ICD-10 coding Documentation Comprehensive Nursing Essay)
- 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.(DSM-5 and ICD-10 coding Documentation Comprehensive Nursing Essay)
- Finally, explain how to improve documentation to support coding and billing for maximum reimbursement.
BY DAY 7 OF WEEK 2
Submit your Assignment.
SUBMISSION INFORMATION
Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the Turnitin Drafts from the Start Here area.
- To submit your completed assignment, save your Assignment as WK2Assgn1_LastName_Firstinitial
- Then, click on Start Assignment near the top of the page.(DSM-5 and ICD-10 coding Documentation Comprehensive Nursing Essay)
- Next, click on Upload File and select Submit Assignment for review.
Rubric
NRNP_6675_Week2_Assignment1_Rubric
NRNP_6675_Week2_Assignment1_Rubric
CriteriaRatingsPts
This criterion is linked to a Learning OutcomeIn the E/M patient case scenario provided:• Assign DSM-5 and ICD-10 codes to services based upon the patient case scenario.(DSM-5 and ICD-10 coding Documentation Comprehensive Nursing Essay)
20 to >17.0 pts
Excellent 90%–100%
DSM-5 and ICD-10 codes assigned to the scenario are correct, with no more than a minor error.
17 to >15.0 pts
Good 80%–89%
DSM-5 and ICD-10 codes assigned to the scenario are mostly correct, with a few minor errors.
15 to >13.0 pts
Fair 70%–79%
DSM-5 and ICD-10 codes assigned to the scenario contain several errors.
13 to >0 pts
Poor 0%–69%
DSM-5 and ICD-10 codes assigned to the scenario contain significant errors, or response is missing.
20 pts
This criterion is linked to a Learning OutcomeIn 1–2 pages, address the following: • Explain what pertinent information, generally, is required in documentation to support DSM-5 and ICD-10 coding.(DSM-5 and ICD-10 coding Documentation Comprehensive Nursing Essay)
25 to >22.0 pts
Excellent 90%–100%
The response accurately and concisely explains what pertinent documentation information is required to support DSM-5 and ICD-10 coding.
22 to >19.0 pts
Good 80%–89%
The response accurately explains what pertinent documentation information is required to support DSM-5 and ICD-10 coding.
19 to >17.0 pts
Fair 70%–79%
The response somewhat vaguely or inaccurately explains what pertinent documentation information is required to support DSM-5 and ICD-10 coding.(DSM-5 and ICD-10 coding Documentation Comprehensive Nursing Essay)
17 to >0 pts
Poor 0%–69%
The response vaguely or inaccurately explains what pertinent documentation information is required to support DSM-5 and ICD-10 coding, or the explanation is incomplete or missing.
25 pts
This criterion is linked to a Learning Outcome• Explain what pertinent documentation is missing from the case scenario, and what other information would be helpful to narrow your coding and billing options.(DSM-5 and ICD-10 coding Documentation Comprehensive Nursing Essay)
25 to >22.0 pts
Excellent 90%–100%
The response accurately and concisely identifies the pertinent misssing information from the case scenario and clearly identifies what additional information would narrow coding and billing options.(DSM-5 and ICD-10 coding Documentation Comprehensive Nursing Essay)
22 to >19.0 pts
Good 80%–89%
The response accurately identifies the pertinent misssing information from the case scenario and identifies what additional information would narrow coding and billing options.(DSM-5 and ICD-10 coding Documentation Comprehensive Nursing Essay)
19 to >17.0 pts
Fair 70%–79%
The response somewhat vaguely or inaccurately identifies the pertinent misssing information from the case scenario and identifies what additional information would narrow coding and billing options.(DSM-5 and ICD-10 coding Documentation Comprehensive Nursing Essay)
17 to >0 pts
Poor 0%–69%
The response vaguely or inaccurately identifies the pertinent misssing information from the case scenario or partially identifies what additional information would narrow coding and billing options, or this information is incomplete or missing.
25 pts
This criterion is linked to a Learning Outcome• Finally, explain how to improve documentation to support coding and billing for maximum reimbursement.(DSM-5 and ICD-10 coding Documentation Comprehensive Nursing Essay)
15 to >13.0 pts
Excellent 90%–100%
The response accurately and concisely explains how to improve documentation to support coding and billing for maximum reimbursement.
13 to >11.0 pts
Good 80%–89%
The response accurately explains how to improve documentation to support coding and billing for maximum reimbursement.
11 to >10.0 pts
Fair 70%–79%
The response somewhat vaguely or inaccurately explains how to improve documentation to support coding and billing for maximum reimbursement.(DSM-5 and ICD-10 coding Documentation Comprehensive Nursing Essay)
10 to >0 pts
Poor 0%–69%
The response vaguely or inaccurately explains how to improve documentation to support coding and billing for maximum reimbursement, or response may be incomplete or missing.
15 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.(DSM-5 and ICD-10 coding Documentation Comprehensive Nursing Essay)
5 to >4.0 pts
Excellent 90%–100%
Paragraphs and sentences follow writing standards for flow, continuity, and clarity…. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.
4 to >3.5 pts
Good 80%–89%
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time…. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive.(DSM-5 and ICD-10 coding Documentation Comprehensive Nursing Essay)
3.5 to >3.0 pts
Fair 70%–79%
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time…. Purpose, introduction, and conclusion of the assignment are vague or off topic.
3 to >0 pts
Poor 0%–69%
Paragraphs and sentences follow writing standards for flow, continuity, and clarity <60% of the time…. Purpose statement, introduction, and conclusion were not provided.(DSM-5 and ICD-10 coding Documentation Comprehensive Nursing Essay)
5 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – English Writing Standards: Correct grammar, mechanics, and proper punctuation(DSM-5 and ICD-10 coding Documentation Comprehensive Nursing Essay)
5 to >4.0 pts
Excellent 90%–100%
Uses correct grammar, spelling, and punctuation with no errors
4 to >3.5 pts
Good 80%–89%
Contains 1-2 grammar, spelling, and punctuation errors
3.5 to >3.0 pts
Fair 70%–79%
Contains 3-4 grammar, spelling, and punctuation errors
3 to >0 pts
Poor 0%–69%
Contains five or more grammar, spelling, and punctuation errors that interfere with the reader’s understanding
5 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – The paper follows correct APA format for parenthetical/in-text citations and reference list.(DSM-5 and ICD-10 coding Documentation Comprehensive Nursing Essay)
5 to >4.0 pts
Excellent 90%–100%
Uses correct APA format with no errors
4 to >3.5 pts
Good 80%–89%
Contains 1-2 APA format errors
3.5 to >3.0 pts
Fair 70%–79%
Contains 3-4 APA format errors
3 to >0 pts
Poor 0%–69%
Contains five or more APA format errors
5 pts
Total Points: 100
DSM-5 and ICD-10 coding Documentation Comprehensive Nursing Essay
Explain what pertinent information, generally, is required in documentation to support DSM-5 and ICD-10 coding.
The DSM-5 and ICD-10 coding are tools used to classify mental disorders using specific criteria and establish definitive diagnoses. Therefore, the salient information required is for DSM-5 is the documentation describing the patient’s conditions and the associated symptoms (American Psychiatric Association [APA], 2013). The descriptions include clinicians’ notes on patients’ conditions and their explanations of their condition. Simply put, the DSM-5 provides a common language for medical personnel to communicate about their patients, establishing reliable diagnoses crucial for clinical intervention and further research. The description and symptoms of a patient’s condition are then used to categorize the mental disorder. The diagnosis code is needed and should be supported by the physician’s documentation of the patient’s medical records. The physician’s coding and documentation should be specific and outlines the procedures performed and the rationale involved. The ICD-10 uses the DSM-5 criteria to report and track the patient’s condition, besides aiding the billing process.(DSM-5 and ICD-10 coding Documentation Comprehensive Nursing Essay)
Explain what pertinent documentation is missing from the case scenario and what other information would be helpful to narrow your coding and billing options.
Appropriate documentation is critical for a definitive diagnosis. In the presented scenario, the missing information includes the review of systems and physical examination of the client. Review of systems allows clinicians to ask questions related to the client’s organ systems to identify the underlying cause and alter the diagnosis and treatment plan (Ball et al., 2019). Physical examination is equally significant as it allows clinicians to appropriately identify and treat physical illness. Information on a patient’s mental health examination, objective measurements, screening, and diagnostic tests are crucial in ascertaining the diagnosis.(DSM-5 and ICD-10 coding Documentation Comprehensive Nursing Essay)
Finally, explain how to improve documentation to support coding and billing for maximum reimbursement.
Improving documentation is necessary to support coding and billing for maximum reimbursement. Herein are the strategies that have been adopted to improve documentation of patients’ conditions and symptoms. First, staff training. Staff training is acknowledged globally and in the health sector as a crucial strategy in enhancing the quality and safety of healthcare. Equally, the providers should be educated on accurate coding, documentation, and the impact of reimbursements. In this case, staff training on various ways to improve documentation and coding of various conditions. Two, the use of Electronic Health Records and other documentation technologies enhances coding accuracy and reimbursement efficiency (Lee & Choi, 2021). Abbasi-Feinberg, F. (2020) describes technology as a redefining tool for healthcare, enhancing the convenience and quality of patients-providers interactions. Significantly, technology enhances work prioritization, effective record keeping, and sharing the information with coders.(DSM-5 and ICD-10 coding Documentation Comprehensive Nursing Essay)
Lastly, investing in personnel with expertise in clinical documentation quality. According to Dehghan et al. (2013), clinical governance is crucial in improving nursing documentation. Clinical governance promotes compliance with existing documentation frameworks across all nursing units. Therefore, clinical governance would compel the relevant personnel to enhance their duties and comply with existing guidelines, improving the technical components of coding and documentation. In sum, there is a need for collaboration among unit staff and managers to ensure seamless communication, collaboration, and feedback regarding coding and documentation of various patient conditions. Equally, every hospital unit would be compelled to participate in coding and documentation and eventually optimize billing and claims management. (DSM-5 and ICD-10 coding Documentation Comprehensive Nursing Essay)
References
Abbasi-Feinberg, F. (2020). Telemedicine coding and reimbursement-current and future trends. Sleep Medicine Clinics, 15(3), 417-429. https://doi.org/10.1016/j.jsmc.2020.06.002
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Publishing, Inc.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Dehghan, M., Dehghan, D., Sheikhrabori, A., Sadeghi, M., & Jalalian, M. (2013). Quality improvement in clinical documentation: does clinical governance work?. Journal of multidisciplinary healthcare, 6, 441. https://dx.doi.org/10.2147%2FJMDH.S53252
Lee, J., & Choi, J. Y. (2021). Improved efficiency of coding systems with health information technology. Scientific Reports, 11(1), 1-6. https://dx.doi.org/10.1038%2Fs41598-021-89869-y
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