Apply DSM-5 diagnosis criteria and ICD-10 codes to patient service documentation Analyze the relationships among documentation, coding, and billing in advanced practice nursing Evaluate mastery of nurse practitioner knowledge in preparation for the nurse practitioner national certification examination Create a study plan for the nurse practitioner national certification examination Assignment 1: 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. For this Assignment, you will review evaluation and management (E/M) documentation for a patient and perform a crosswalk of codes from DSM-5 to ICD-10

Relevant Information
DSM-5-TR and Updated ICD-10 paperwork must incorporate important information. First, describe the patient's main complaint. These represent the patient's symptoms, including frequency, intensity, duration, and impairment or distress. Document any past psychiatric or substance use treatment, hospitalizations, or pharmaceutical trials. The patient's psychosocial history—upbringing, education, work, and relationships—can also provide background. Documentation includes the MSE. It evaluates the appearance of the patient, their speech, thought process, and mood. It also affects perception, cognition, and insight. MSE observations aid diagnostic evaluation and DSM-5-TR diagnosis.
The PHQ-9, GAD-7, MDQ, and PCL-5 values must be included to aid coding. Screening results quantify symptom severity and aid diagnosis. Documentation should also analyze suicide and homicide risk, including risk and protective factors. Document the patient's suicide and self-harm history and risk level (Walden University Academic Skills Center, 2017). Include the safety plan and patient-discussed precautions. In addition, the treatment plan should include medication modifications or prescriptions, patient education about risks and benefits, side effects, and adverse reaction monitoring and reporting: document therapy referrals, emergency contacts, and follow-up plans.
Ultimately, DSM-5-TR and Updated ICD-10 documentation should include a detailed analysis and description of the presenting problem, relevant medical and psychosocial history, diagnostic screening tool results, suicide and homicide risk assessment, treatment plan, and referrals or follow-up. This detailed documentation ensures accurate coding and records the patient's evaluation and treatment.
Describe the missing paperwork and additional information that might aid in narrowing your coding and billing possibilities.
The client's present living conditions, social network, and significant life events or stressors are missing in the case scenario. This knowledge helps analyze the client's psychosocial functioning and understand their symptoms and surroundings. PTSD, ADHD, and stimulant disorder therapy history might also be beneficial. Knowing the particular modalities or therapies they've employed, the length and frequency of their treatment, and the ef...

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