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Assignment 1: Evaluation and Management (E/M)

Student's Name

Code and Course Name

Professor's Name

Institution of Learning

City, State

Date

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Evaluation and Management (E/M)

Evaluation and Management (E/M) is a medical coding system used by physicians and

other health practitioners to document services ranging from patients’ examination, diagnosis to

medical decisions for purposes of reimbursement. The E/M codes must be used by qualified

healthcare providers to be reimbursed by Medicare, Medicaid and other private insurance

companies (Merrick, 2020). The coding applies to both new and established patients. The

medical coding should be captured correctly to avoid instances where reimbursements are either

delayed, denied or some services not paid for (partial reimbursements).

Assign DSM-5 and ICD-10 codes to services based upon the patient case scenario.

There are various types of codes depending on the services offered, for example, for

consultation, examination, outpatient services, and emergency department services among others.

The Diagnostic and Statistical Manual of Mental Disorders (DSM–5) is a guide for assessment

and diagnosis of mental disorders (Chmielewski et al., 2015). However, it does not contain

information for treatment of any mental disorder or in simple terms, they are not mental

disorders codes. On the other hand, the International Classification of Diseases, Tenth Revision,

Clinical Modification (ICD-10) codes provide more detailed information for assessing healthcare

service quality, care and value (Khera et al., 2018). Due to this, they are useful for ensuring

value-based reimbursement and the design of compensation structures and claims processing.

The main functional difference between DSM-5 and ICD-10 is that the former is used as a

common language among the mental healthcare providers in classifying diseases while the latter

assigns the codes used for reimbursement purposes. In the Diagnostic impression part for the

case scenario, some of the expected coding include: 90837 for services exceeding 53 minutes,

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this one took 57 minutes; 90792 for Psychiatric Diagnostic Evaluation with medical services and

F41.1 for Generalized anxiety disorder.

Explain what pertinent information, generally, is required in documentation to support

DSM-5 and ICD-10 coding.

In order to document a reliable DSM-5 and ICD-10 coding, several information or details

are required. If any of the information is missing, it may either lead to poor quality of care for

patients or underpayment of services offered by payers or insurance schemes (Horsky et al.,

2018). Some of the pertinent components of DSM-5 and ICD-10 coding include: history;

examination; medical decision making; counseling; coordination of care; nature of presenting

problem; and time. These components are further broken down into specifics. For example, in

history, some of the important information to capture includes: the chief complaint (CC) and

history of present illness (HPI), a comprehensive review of systems (ROS), and a relevant past,

family, and/or social history (PFSH). In the case of a 25 year old Russian female patient, there

are several important details that have been captured which include: the time spent in assessing

the patient. Also, History of Present Illness is comprehensively captured. Other necessary

information captured during the evaluation of the patient are: substance use history, suicide risk

assessment, mental status examination and treatment plan among others as highlighted.

Explain what pertinent documentation is missing from the case scenario, and what other

information would be helpful to narrow your coding and billing options.

From this case scenario, most of the important processes and documentations are done.

However, since this is a case of an established patient, it was vital to review her documents to

have a better understanding of the diagnosis and progress of her condition as per her

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engagements with the retired provider. In addition, this would have narrowed the process of

coding and billing.

Finally, explain how to improve documentation to support coding and billing for maximum

reimbursement.

To ensure maximum reimbursement, hospitals can improve their documentation

structures by adopting efficient systems like Electronic Medical Records (EMRs). It is easy to

update the records as compared to the traditional medical records. In addition, health

practitioners and other staff members should be regularly trained on different codes and the

importance of exercising correct coding in order to reduce chances of delayed or partial

reimbursements.

Since the insurance schemes and other payers have contractual obligations with the

enrollees, they require that the coding and documentations are consistent and reliable. In case of

a claim, they may require additional information which includes justification for the services

offered. It is therefore imperative that health facilities develop a good documentation culture that

guarantees maximum reimbursement of services rendered to patients.

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References

Chmielewski, M., Clark, L. A., Bagby, R. M., & Watson, D. (2015). Method matters:

Understanding diagnostic reliability in DSM-IV and DSM-5. Journal of Abnormal

Psychology, 124(3), 764-769. https://doi.org/10.1037/abn0000069

Horsky, J., Drucker, E. A., & Ramelson, H. Z. (2018). Accuracy and Completeness of Clinical

Coding Using ICD-10 for Ambulatory Visits. AMIA ... Annual Symposium proceedings.

AMIA Symposium, 2017, 912–920

Khera, R., Dorsey, K. B., & Krumholz, H. M. (2018). Transition to the ICD-10 in the United

States. JAMA, 320(2), 133. https://doi.org/10.1001/jama.2018.6823

Merrick, S. K. (2020). Office/Outpatient evaluation and management: Changes ahead. ASA

Monitor, 84(8), 19-21. https://doi.org/10.1097/01.m99.0000695148.93802.e5

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