Pertinent information
• 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.
In the case scenario provided there was an inadequate amount of pertinent information present to be able to provide an accurate code for DSM 5-TR and ICD 10 coding. The clinician failed to note details about the patient’s age or gender which would have been useful when developing a more detailed assessment plan. Furthermore, there was not enough detail regarding KW’s family history: whether she has children or siblings who could assist with her care; whether she had any prior mental health treatment; how long ago was she discharged from treatment? This additional detail would help narrow down possible billing options based on what type of services were provided by the PMHNP.
To improve documentation to support coding and billing for maximum reimbursement clinicians must ensure they document all pertinent information related to the patient including but not limited to: age, gender identity (if applicable), cultural background (race/ethnicity), marital status, employment status etc., as well as a comprehensive description of their presenting symptoms; psychiatric/medical history; medications taken; social supports available; functional capacity assessments are all key elements in helping accurately assess patients condition(s) and develop effective treatments plans. Clinicians must also sign off on each entry with their signature date so that it can easily be referenced at a later time if needed. Finally they need to ensure they use accepted terminology according understandable language both laypeople professionals alike order comply guidelines set forth respective regulating bodies ensuring appropriate reimbursement citing Matheny & Ward 2018 .