NRNP 6675 Evaluation and Management (E/M) Walden
Pathways Mental Health
Psychiatric Patient Evaluation
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| Instructions | Use the following case template to complete Week 2 Assignment 1. On page 5, assign DSM-5-TR and Updated ICD-10 codes to the services documented. You willadd yournarrative answers to the assignment questions to the bottom of this template and submit altogether as one document. | ||
| Identifying Information | 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.” | ||
| HPI | 25 yo Russian female evaluated for psychiatric evaluation referred from her retiring practitioner for PTSD, 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. |
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| Diagnostic Screening Results | Screen of symptoms in the past 2 weeks:
PHQ 9= 0 with symptoms rated as no difficulty in functioning GAD 7= 2 with symptoms rated as no difficulty in functioning MDQ screen negative PCL-5 Screen 32 |
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| 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: deniedPrevious Detox/Residential treatments: one for abuse of stimulants and cocaine in 2015Previous 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 | ||
| Substance Use History | Have you used/abused any of the following (include frequency/amt/last use):
Substance Y/N Frequency/Last Use Tobacco products Y ½ ETOH Y last drink 2 weeks ago, reports drinks 1-2 times monthly one drink socially Cannabis N Cocaine Y last use 2015 Prescription stimulants Y last use 2015 Methamphetamine N Inhalants N Sedative/sleeping pills N Hallucinogens N Street Opioids N Prescription opioids N Other: specify (spice, K2, bath salts, etc.) Y reports one-time ecstasy use in 2015 Any history of substance related: Blackouts: + Tremors: -DUI: – D/T’s: -Seizures: – Longest sobriety reported since 2015—stayed sober maintaining sponsor, sober friends, and meetings |
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| Psychosocial History | Client was raised by adoptive parents since age 6; from Russian orphanage. She has unknown siblings. She is single; has no children. Employed at local tanning bed salon Education: High School Diploma Denied current legal issues. | ||
| Suicide / HOmicide Risk Assessment | RISK FACTORS FOR SUICIDE: Suicidal Ideas or plans – noSuicide gestures in past – no Psychiatric diagnosis – yesPhysical Illness (chronic, medical) – noChildhood trauma – yesCognition not intact – noSupport system – yesUnemployment – noStressful life events – yesPhysical abuse – yesSexual abuse – yesFamily history of suicide – unknownFamily history of mental illness – unknownHopelessness – noGender – femaleMarital status – singleWhite raceAccess to meansSubstance abuse – in remission PROTECTIVE FACTORS FOR SUICIDE: Absence of psychosis – yesAccess to adequate health care – yesAdvice & help seeking – yesResourcefulness/Survival skills – yesChildren – noSense of responsibility – yesPregnancy – no; last menses one week ago, has NorplantSpirituality – yesLife satisfaction – “fair amount”Positive coping skills – yesPositive social support – yesPositive therapeutic relationship – yesFuture oriented – yes Suicide Inquiry: Denies active suicidal ideations, intentions, or plans. Denies recent self-harm behavior. Talks futuristically. Denied history of suicidal/homicidal ideation/gestures; denied history of self-mutilation behaviors Global Suicide Risk Assessment: The client is found to be at low risk of suicide or violence, however, risk of lethality increased under context of drugs/alcohol. No required SAFETY PLAN related to low risk | ||
| Mental Status Examination | 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. | ||
| Clinical Impression | 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. | ||
| Diagnostic Impression | [Student to provide DSM-5-TR and Updated ICD-10 coding] Posttraumatic Stress Disorder (PTSD) DSM-5 309.81; ICD-10 F43. 10Attention-Deficit Hyperactivity Disorder DSM-5 314.01; ICD-10 F90.0 | ||
| Treatment Plan | Medication: Increase fluoxetine 40mg po daily for PTSD #30 1 RFContinue with atomoxetine 80mg po daily for ADHD. #30 1 RF
Instructed to call and report any adverse reactions. Future Plan: monitor for decrease re-experiencing, hyperarousal, and avoidance symptoms; monitor for improved concentration, less mistakes, less forgetful Education: Risks and benefits of medications are discussed including non-treatment. Potential side effects of medications discussed. Verbal informed consent obtained. Not to drive or operate dangerous machinery if feeling sedated. Not to stop medication abruptly without discussing with providers. Discussed risks of mixing medications with OTC drugs, herbal, alcohol/illegal drugs. Instructed to avoid this practice. Praised and Encouraged ongoing abstinence. Maintain support system, sponsors, and meetings. Discussed how drugs/ETOH affects mental health, physical health, sleep architecture. Patient was educated about therapy and services of the MHC including emergent care. Referral was sent via email to therapy team for PET treatment. Patient has emergency numbers: Emergency Services 911, the national Crisis Line 800-273-TALK, the MHC Crisis Clinic. Patient was instructed to go to nearest ER or call 911 if they become actively suicidal and/or homicidal. Time allowed for questions and answers provided. Provided supportive listening. Patient appeared to understand discussion and appears to have capacity for decision making via verbal conversation. RTC in 30 days Follow up with PCP for GI upset and headaches, reviewed PCP history and physical dated one week ago and include lab results Patient is amenable with this plan and agrees to follow treatment regimen as discussed. |
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Narrative Answers
In order to support DSM-5-TR coding, documentation should include a range of pertinent information. This includes the patient’s diagnostic features, such as symptoms and behaviors, that are in line with the DSM-5 criteria for the specific disorder. It’s important to document related clinical features that support the diagnosis, diagnostic measures that have been used, prognostic factors that may affect the course of the disorder, clinical subtypes if applicable, and any functional consequences of the condition. Additionally, documenting the process of arriving at the diagnosis, including the differential diagnosis considered, is crucial. Cultural and gender-related diagnostic issues should also be addressed, as they can influence the diagnosis and treatment (Regier & Narrow, 2018).
For ICD-10 coding, the documentation should encompass different aspects. This includes documenting the signs and symptoms that are relevant to the patient’s condition. It’s essential to specify the cause of the disease or injury, indicating if it’s a result of a specific event or underlying condition. The anatomical site of the condition, its type, time of onset, and severity are also crucial details. Documenting the type of patient encounter (e.g., initial, subsequent, or sequela) is necessary for accurate coding. Specificity is vital, such as whether the patient lost consciousness, the disease’s status (acute or chronic), and whether there is relief or non-relief of symptoms. The documentation should also cover the interventions being performed and the location of the incident or treatment (Clements, 2022).
Pertinent documentation that is missing from the case scenario includes information about the type of clinical encounter, the severity of the patient’s clinical manifestations, comorbidities, and the primary and differential diagnoses along with their ICD-10 and DSM-5 codes. In addition, crucial details about the patient, healthcare provider, and clinic visit are absent. Patient information, such as the name, date of birth, onset of symptoms, and insurance details, can significantly aid in coding and billing accuracy. Healthcare provider details, including the name, signature, address, and national provider identifier (NPI) number, are vital for proper documentation. Clinic visit details, such as the type of visit, date and time, diagnosis and procedure codes, code modifiers, authorization information, and the items used for assessment, diagnosis, and treatment should also be included to narrow down coding and billing options (Kusnoor et al., 2020).
To improve documentation for coding and billing for maximum reimbursement, healthcare practitioners should adhere to certain guidelines. They should ensure that the patient’s diagnosis is correctly and comprehensively specified to support accurate coding. Physicians, nurse practitioners, and physician assistants are typically responsible for assigning codes based on the provided documentation. Nurses’ notes, on the other hand, should not be coded to prevent potential inaccuracies (Clements, 2022). Additionally, clinical documentation can be enhanced by clearly delineating cause-and-effect relationships using phrases like “because of” and “manifested by.” Primary diagnoses should be clearly indicated, as these are the conditions primarily responsible for the patient’s admission. Moreover, the use of terms like “probable,” “suspected,” and “rule out” can be helpful when a conclusive diagnosis is not yet available, allowing for appropriate coding and billing (Clements, 2022).
References
Clements, J. (2022). Thorough documentation for accurate ICD-10 coding. Outsource Strategies International.
Regier, D. A., & Narrow, W. E. (2018). Understanding ICD-10-CM and DSM-5: A quick guide for psychiatrists and other mental health clinicians. Retrieved September, 20, 2018.
Kusnoor, S. V., Blasingame, M. N., Williams, A. M., DesAutels, S. J., Su, J., & Giuse, N. B. (2020). A narrative review of the impact of the transition to ICD-10 and ICD-10-CM/PCS. JAMIA open, 3(1), 126-131. https://doi.org/10.1093/jamiaopen/ooz066
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