Evaluation and Management (E/M)

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 will add your narrative answers to the assignment questions to the bottom of this template and submit altogether as one document.

Identification was verified by stating of their name and date of birth.
Time spent for evaluation: 0900am-0957am

“My other provider retired. I don’t think I’m doing so well.”

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.

Screen of symptoms in the past 2 weeks: 
PHQ 9 = 0 with symptoms rated as no difficulty in functioning 
Interpretation of Total Score 
Total Score Depression Severity 1-4 Minimal depression 5-9 Mild depression 10-14 Moderate depression 15-19 Moderately severe depression 20-27 Severe depression 
GAD 7 = 2 with symptoms rated as no difficulty in functioning 
Interpreting the Total Score: 
Total Score Interpretation ≥10 Possible diagnosis of GAD; confirm by further evaluation 5 Mild Anxiety 10 Moderate anxiety 15 Severe anxiety 
MDQ screen negative
PCL-5 Screen 32

Entered mental health system when she was age 19 after raped by a stranger during a house burglary.
Previous Psychiatric Hospitalizations:  denied
Previous Detox/Residential treatments: one for abuse of stimulants and cocaine in 2015
Previous 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

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

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.

RISK FACTORS FOR SUICIDE:
Suicidal Ideas or plans – no
Suicide gestures in past – no
Psychiatric diagnosis – yes
Physical Illness (chronic, medical) – no
Childhood trauma – yes
Cognition not intact – no
Support system – yes
Unemployment – no
Stressful life events – yes
Physical abuse – yes
Sexual abuse – yes
Family history of suicide – unknown
Family history of mental illness – unknown
Hopelessness – no
Gender – female
Marital status – single
White race
Access to means
Substance abuse – in remission
PROTECTIVE FACTORS FOR SUICIDE:
Absence of psychosis – yes
Access to adequate health care – yes
Advice & help seeking – yes
Resourcefulness/Survival skills – yes
Children – no
Sense of responsibility – yes
Pregnancy – no; last menses one week ago, has Norplant
Spirituality – yes
Life satisfaction – “fair amount”
Positive coping skills – yes
Positive social support – yes
Positive therapeutic relationship – yes
Future 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

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.

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.

[Student to provide DSM-5-TR and Updated ICD-10 coding]
Double click inside this text box to add/edit text. Delete placeholder text when you add your answers.

Medication:
Increase fluoxetine 40mg po daily for PTSD #30 1 RF
Continue 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.

· Explain what pertinent information, generally, is required in documentation to support DSM-5-TR and Updated 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.]

Add your answers here. Delete instructions and placeholder text when you add your answers.

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