Evaluation and Management (E/M)

Use the following case template to complete Week 2 Assignment 1. On page 5, assign DSM-5 and 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.
Identification was verified by stating of their name and date of birth.
Time spent for evaluation: 0900am-0957am
CHIEF COMPLAINT: “My other provider retired. I don’t think I’m doing so well.”
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, self-inflated 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.
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
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 • 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
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.
Based on the information above please provide the following answers.
Question 1.
Question 2.
• Explain what pertinent information, generally, is required in documentation to support DSM-5 and ICD-10
Question 3.
• Explain what pertinent documentation is missing from the case scenario, and what other information would be
helpful to narrow your coding and billing options.
Question 4
• Finally, explain how to improve documentation to support coding and billing for maximum reimbursement.]

Sample Solution