Pathways Mental Health
\nPSYCHIATRIC PATIENT Assessment
\nINSTRUCTIONS\t\tUse the following case template to complete week 2 [Essay writing service – your education, our expertise: Get any assignment done with our professional essay writers before your deadlines – Zero AI, Human experts and Fast delivery.] Assignment 1. On page 5, assign DSM-5-TR and Updated 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.
\nIDENTIFYING INFORMATION\t\tIdentification was verified by stating of their name and date of birth.
\nTime spent for Assessment: 0900am-0957am<\/p>\n
CHIEF COMPLAINT\t\t\u201cMy other provider retired. I don\u2019t think I\u2019m doing so well.\u201d<\/p>\n
HPI\t\t25 yo Russian female evaluated for psychiatric Assessment 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.<\/p>\n
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\u20136 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. Today, the client denied having depressive symptoms, anhedonia, anhedonia-like symptoms, amotivation, anxiety, frequent worry, reports of feeling restless, no reported symptoms of panic attacks, and no reported obsessive\/compulsive behaviors. Client disputes any current SI\/HI ideas, plans, or intentions. Psychosis or delusional thinking are not present. The client denied having ever experienced hypomania, hyperactivity, erratic or excessive spending, engaging in risky activities, or having an inflated sense of self or grandiosity. The client reports that she is becoming more irritable and easily frustrated, loses things easily, makes mistakes, finds it difficult to focus and concentrate, which has an impact on her job. Has a low tolerance for frustration, sleeps 5 to 6 hours per day, reports having nightmares about being raped, isolates himself, is afraid to go outside, has missed several days of work, and his appetite has decreased. She experiences headaches and GI upset, which are somatic issues. Client denied engaging in any current bingeing or purging, food withholding, or anorexic behaviors. No actions of self-mutilation.<\/p>\n
DIAGNOSTIC SCREENING RESULTS\t\tScreen of symptoms in the past 2 weeks:<\/p>\n
PHQ 9 = 0 with symptoms rated as no difficulty in functioning
\nInterpretation of Total Score
\nTotal Score Depression Severity 1-4 Minimal depression 5-9 Mild depression 10-14 Moderate depression 15-19 Moderately severe depression 20-27 Severe depression<\/p>\n
GAD 7 = 2 with symptoms rated as no difficulty in functioning
\nInterpreting the Total Score:
\nTotal Score Interpretation \u226510 Possible diagnosis of GAD; confirm by further Assessment 5 Mild Anxiety 10 Moderate anxiety 15 Severe anxiety<\/p>\n
MDQ screen negative<\/p>\n
PCL-5 Screen 32<\/p>\n
PAST PSYCHIATRIC AND SUBSTANCE USE TREATMENT\t\t\u2022\tEntered mental health system when she was age 19 after raped by a stranger during a house burglary.
\n\u2022\tPrevious Psychiatric Hospitalizations: denied
\n\u2022\tPrevious Detox\/Residential treatments: one for abuse of stimulants and cocaine in 2015
\n\u2022\tPrevious psychotropic medication trials: sertraline (became suicidal), trazodone (worsened nightmares), bupropion (became suicidal), Adderall (began abusing)
\n\u2022\tPrevious mental health diagnosis per client\/medical record: GAD, Unspecified Trauma, PTSD, Stimulant use disorder, ADHD confirmed by school records<\/p>\n
SUBSTANCE USE HISTORY\t\tHave you used\/abused any of the following (include frequency\/amt\/last use):<\/p>\n
Substance\tY\/N\tFrequency\/Last Use
\nTobacco products\tY\t\u00bd
\nETOH\tY\tlast drink 2 weeks ago, reports drinks 1-2 times monthly one drink socially
\nCannabis\tN
\nCocaine\tY\tlast use 2015
\nPrescription stimulants\tY\tlast use 2015
\nMethamphetamine\tN
\nInhalants\tN
\nSedative\/sleeping pills\tN
\nHallucinogens\tN
\nStreet Opioids\tN
\nPrescription opioids\tN
\nOther: specify (spice, K2, bath salts, etc.)\tY\treports one-time ecstasy use in 2015<\/p>\n
Any history of substance related:
\n\u2022\tBlackouts: +
\n\u2022\tTremors: –
\n\u2022\tDUI: –
\n\u2022\tD\/T’s: –
\n\u2022\tSeizures: –
\nLongest sobriety reported since 2015\u2014stayed sober maintaining sponsor, sober friends, and meetings<\/p>\n
PSYCHOSOCIAL HISTORY\t\tClient was raised by adoptive parents since age 6; from Russian orphanage. She has unknown siblings. She is single; has no children.
\nEmployed at local tanning bed salon
\nEducation: High School Diploma
\nDenied current legal issues.<\/p>\n
SUICIDE \/ HOMICIDE RISK ASSESSMENT\t\tRISK FACTORS FOR SUICIDE:
\n\u2022\tSuicidal Ideas or plans – no
\n\u2022\tSuicide gestures in past – no
\n\u2022\tPsychiatric diagnosis – yes
\n\u2022\tPhysical Illness (chronic, medical) – no
\n\u2022\tChildhood trauma – yes
\n\u2022\tCognition not intact – no
\n\u2022\tSupport system – yes
\n\u2022\tUnemployment – no
\n\u2022\tStressful life events – yes
\n\u2022\tPhysical abuse – yes
\n\u2022\tSexual abuse – yes
\n\u2022\tFamily history of suicide – unknown
\n\u2022\tFamily history of mental illness – unknown
\n\u2022\tHopelessness – no
\n\u2022\tGender – female
\n\u2022\tMarital status – single
\n\u2022\tWhite race
\n\u2022\tAccess to means
\n\u2022\tSubstance abuse – in remission<\/p>\n
PROTECTIVE FACTORS FOR SUICIDE:
\n\u2022\tAbsence of psychosis – yes
\n\u2022\tAccess to adequate health care – yes
\n\u2022\tAdvice & help seeking – yes
\n\u2022\tResourcefulness\/Survival skills – yes
\n\u2022\tChildren – no
\n\u2022\tSense of responsibility – yes
\n\u2022\tPregnancy – no; last menses one week ago, has Norplant
\n\u2022\tSpirituality – yes
\n\u2022\tLife satisfaction – \u201cfair amount\u201d
\n\u2022\tPositive coping skills – yes
\n\u2022\tPositive social support – yes
\n\u2022\tPositive therapeutic relationship – yes
\n\u2022\tFuture oriented – yes<\/p>\n
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<\/p>\n
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.<\/p>\n
No required SAFETY PLAN related to low risk<\/p>\n
MENTAL STATUS EXAMINATION\t\tShe 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.<\/p>\n
CLINICAL IMPRESSION\t\tClient is a 25 yo Russian female who presents with history of treatment for PTSD, ADHD, Stimulant use Disorder, in remission.
\nMoods 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.
\nAt 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.<\/p>\n
DIAGNOSTIC IMPRESSION\t\t[STUDENT TO PROVIDE DSM-5-TR AND UPDATED ICD-10 CODING]<\/p>\n
Double click inside this text box to add\/edit text. Delete placeholder text when you add your answers.<\/p>\n
TREATMENT PLAN\t\t1)\tMedication:
\n\u2022\tIncrease fluoxetine 40mg po daily for PTSD #30 1 RF
\n\u2022\tContinue with atomoxetine 80mg po daily for ADHD. #30 1 RF<\/p>\n
Instructed to call and report any adverse reactions.<\/p>\n
Future Plan: monitor for decrease re-experiencing, hyperarousal, and avoidance symptoms; monitor for improved concentration, less mistakes, less forgetful<\/p>\n
2)\tEducation: Risks and benefits of medications are discussed including non-treatment. Potential side effects of medications discussed. Verbal informed consent obtained.<\/p>\n
Not to drive or operate dangerous machinery if feeling sedated.<\/p>\n
Not to stop medication abruptly without discussing with providers.<\/p>\n
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.<\/p>\n
Discussed how drugs\/ETOH affects mental health, physical health, sleep architecture.<\/p>\n
3)\tPatient was educated about therapy and services of the MHC including emergent care. Referral was sent via email to therapy team for PET treatment.<\/p>\n
4)\tPatient 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.<\/p>\n
5)\tTime 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.<\/p>\n
6)\tRTC in 30 days<\/p>\n
7)\tFollow up with PCP for GI upset and headaches, reviewed PCP history and physical dated one week ago and include lab results<\/p>\n
Patient is amenable with this plan and agrees to follow treatment regimen as discussed.<\/p>\n
NARRATIVE ANSWERS
\n[IN 1-2 PAGES, ADDRESS THE FOLLOWING:
\n\u2022\tExplain what pertinent information, generally, is required in documentation to support DSM-5-TR and Updated ICD-10 coding.
\n\u2022\tExplain what pertinent documentation is missing from the case scenario, and what other information would be helpful to narrow your coding and billing options.
\n\u2022\tFinally, explain how to improve documentation to support coding and billing for maximum reimbursement.]<\/p>\n
Add your answers here. Delete instructions and placeholder text when you add your answers.<\/p>\n
REFERENCES
\n[ADD APA-FORMATTED CITATIONS FOR ANY SOURCES YOU REFERENCED<\/p>\n
Delete instructions and placeholder text when you add your citations.<\/p>\n
Assignment
\nInsurance 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.
\nFor this Assignment, you will review Assessment and management (E\/M) documentation for a patient and perform a crosswalk of codes from DSM-5-TR to ICD-10.
\n\u2022\tReview this week\u2019s Learning Resources on coding, billing, reimbursement.
\n\u2022\tReview the E\/M patient case scenario provided.
\n\u2022\tAssign DSM-5-TR and ICD-10 codes to services based upon the patient case scenario.
\nThen, in 1\u20132 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.
\n\u2022\tExplain what pertinent information, generally, is required in documentation to support DSM-5-TR and ICD-10 coding.
\n\u2022\tExplain what pertinent documentation is missing from the case scenario, and what other information would be helpful to narrow your coding and billing options.
\n\u2022\tFinally, explain how to improve documentation to support coding and billing for maximum reimbursement.
\nRUBRIC In the E\/M patient case scenario provided:\u2022 Assign DSM-5 and ICD-10 codes to services based upon the patient case scenario.
\nDSM-5 and ICD-10 codes assigned to the scenario are correct, with no more than a minor error.
\nThe response accurately and concisely explains what pertinent documentation information is required to support DSM-5 and ICD-10 coding.
\nThe response accurately and concisely identifies the pertinent missing information from the case scenario and clearly identifies what additional information would narrow coding and billing options.
\nThe response accurately and concisely explains how to improve documentation to support coding and billing for maximum reimbursement.
\nParagraphs 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.<\/p>\n","protected":false},"excerpt":{"rendered":"
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