Documentation to support DSM-5-TR and ICD-10 coding.

• 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.

Full Answer Section

   
  1. History of Present Illness (HPI): A detailed chronological account of the patient's symptoms, including their progression, any associated medical conditions, and any interventions or treatments previously received.

  2. Past Psychiatric History (PPH): A comprehensive overview of the patient's past psychiatric history, including any previous diagnoses, treatments, hospitalizations, or substance use.

  3. Mental Status Examination (MSE): A thorough assessment of the patient's current mental state, including their appearance, behavior, speech,

Sample Answer

   

Pertinent Information for DSM-5-TR and ICD-10 Coding

Accurate and comprehensive documentation is crucial for supporting DSM-5-TR and ICD-10 coding. Proper documentation ensures that diagnoses are assigned correctly, facilitating effective treatment planning, and enabling accurate billing and reimbursement.

Key Elements of Pertinent Documentation

  1. Presenting Problem: A clear description of the patient's presenting problem, including the chief complaint, duration of symptoms, and any aggravating or alleviating factors.