Instructions

Identifying Information

Time spent for evaluation: 1103am-1151am

Chief Complaint

HPI

Today, the client reported symptoms of worsening in the past month for depression with anergia, anhedonia, motivation, reports anxiety, frequent worry, reports feeling restlessness, palpitations, “feels like everything is closing in on me, can’t focus, hard time breathing,” no reported obsessive/compulsive behaviors. Client reported feeling like wanting to sleep and never wake up. 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 is easily frustrated. Has low frustration tolerance, sleeping 10-12 hrs/24hrs, 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.

Diagnostic Screening Results

Past Psychiatric and Substance Use Treatment

·         Previous Psychiatric Hospitalizations:

·         Previous Detox/Residential treatments:

·         Previous psychotropic medication trials: sertraline (became suicidal), trazodone (worsened nightmares), bupropion (became suicidal)

·         Previous mental health diagnosis per client/medical record:

Substance Use History

Have you used/abused any of the following (include frequency/amt/last use):

Any history of substance-related:

·         Blackouts:  –

·         Tremors:   –

·         DUI: –

·         D/T’s: –

·         Seizures: –

Longest sobriety

Psychosocial History

Employed at local day care as administrative assistant.

Education: High School Diploma

Denied current legal issues.

Suicide / Homicide Risk Assessment

Mental Status Examination

She is a 42 yo Hispanic female who looks her stated age. She is cooperative with examiner. She is disheveled, dressed appropriately. There is psychomotor restlessness. Her. Her mood is anxious and mildly irritable. She denies any auditory or visual hallucinations. There is no evidence of any delusional thinking. She denies any current suicidal or homicidal ideation.

Clinical Impression

Moods are anxious and irritable. She has reported symptoms related to her depression and panic. No evident mania/hypomania, no psychosis, 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 ideation, plans, or intent, is able to distinguish right from wrong, and can anticipate the potential consequences of behaviors and actions.

Diagnostic Impression

Primary Diagnosis
Major Depressive Disorder, recurrent episode, moderate – ICD-10 Code: F33.1

The patient reports symptoms consistent with major depressive disorder, including anhedonia, decreased motivation, hypersomnia with sleep lasting ten to twelve hours daily, reduced appetite, fatigue, irritability, and difficulty concentrating. The history also indicates worsening depressive symptoms over the previous month and a prior history of depression that required psychiatric treatment beginning at age twenty-nine. The recurrence of depressive symptoms combined with functional impairment and absence of manic or hypomanic episodes supports the diagnosis of recurrent major depressive disorder according to DSM-5-TR diagnostic criteria (American Psychiatric Association, 2022).

Secondary Diagnosis

Panic disorder – ICD-10 Code: F41.0

The patient describes recurrent panic symptoms, including palpitations, shortness of breath, restlessness, and feelings that “everything is closing in.” These symptoms are accompanied by intense anxiety and impaired concentration. The severity scale for panic disorder shows a total score of thirty-eight, which indicates significant panic symptom severity. The recurrent panic attacks and persistent anxiety symptoms support the DSM-5-TR diagnosis of panic disorder.

Treatment Plan

·         Increase escitalopram 10mg po daily

·         Continue with alprazolam
Instructed to call and report any adverse reactions.

2)       Order labs

3)       Patient has emergency numbers: Emergency Services 911, the national Crisis Line 800-273-TALK, the MHC Crisis Clinic. Patient was instructed to go to the nearest ER or call 911 if they become actively suicidal and/or homicidal.

4)      Time allowed for questions and answers provided. Provided supportive listening.

5)       RTC in 30 days

6)       Follow up with PCP for GI upset and headaches

Complete documentation must support DSM-5-TR diagnosis, ICD-10 diagnostic coding, and CPT billing claims. Psychiatric records should include a detailed history of present illness that explains symptom onset, duration, severity, and effects on daily functioning. Documentation should also contain psychiatric treatment history, medical history, medication history, and substance use history. The mental status examination must describe appearance, behavior, speech, mood, affect, thought process, cognition, insight, and judgment. Suicide and homicide risk assessment represent essential components of psychiatric evaluation and must appear in the documentation. Psychosocial factors such as family relationships, occupational functioning, and environmental stressors should also be documented in the record, as they influence mental health outcomes. Diagnostic reasoning must explain how reported symptoms meet DSM-5-TR diagnostic criteria for conditions such as major depressive disorder or panic disorder (American Psychiatric Association, 2022). Clear clinical reasoning supports correct ICD-10 coding and confirms medical necessity for psychiatric services. Accurate and detailed documentation strengthens reimbursement claims and demonstrates that the evaluation meets professional practice standards.

Several important documentation elements are missing from the case scenario, limiting accurate coding and billing decisions. The record does not include a complete family psychiatric history, which helps identify genetic risk factors for mood and anxiety disorders. A detailed medical history, including chronic illnesses such as endocrine disorders or neurological conditions, is also absent. The documentation lacks allergy information and a complete medication list, including non-psychiatric medications. Vital signs and physical health findings do not appear in the record, even though psychotropic medication management occurred. A review of systems that evaluates physical symptoms associated with psychiatric disorders is also missing. Documentation does not include a detailed trauma history, social determinants of health assessment, or description of occupational functioning and role performance. The suicide risk assessment lacks documentation of protective factors and coping strategies. The record also lacks documentation of informed consent for medication adjustments. Diagnostic reasoning that explains how symptoms meet DSM criteria does not appear. Missing information may affect insurance reimbursement because payers require documentation that clearly supports medical necessity (Centers for Medicare and Medicaid Services, 2023).

Legal and ethical concerns may occur when inaccurate billing practices appear in healthcare documentation. Overbilling occurs when services billed exceed the care actually provided. Upcoding occurs when a higher-level billing code is assigned even when documentation supports a lower-level service. Fraudulent billing occurs when false claims are made to obtain reimbursement from insurance programs. These practices violate federal healthcare regulations and may result in financial penalties, legal action, or disciplinary action by professional organizations. Ethical practice requires billing codes that accurately represent the evaluation and treatment documented in the medical record. Two strategies can promote ethical coding practices in psychiatric practice. First, healthcare professionals should participate in ongoing education regarding CPT coding guidelines, ICD diagnostic coding, and documentation requirements. Continuing education improves understanding of billing regulations and reduces documentation errors (Rhee et al., 2024). Second, healthcare organizations should implement routine audits of documentation and compliance reviews. Regular review of clinical records helps identify documentation gaps, improve coding accuracy, and maintain professional accountability. Strong documentation practices support accurate reimbursement and maintain ethical standards in healthcare practice.

17 to >15.0 ptsGood 80%–89%DSM-5-TR diagnoses, ICD-10, and reimbursement codes assigned to the scenario are mostly correct, with 1-2 minor errors. Response is justified but does not demonstrate critical thinking.

15 to >13.0 ptsFair 70%–79%Missing one of the DSM-5-TR diagnoses, ICD-10, or reimbursement codes assigned to the scenario; contains 2-3 significant errors. Justification is vague or inaccurate.

13 to >0 ptsPoor 0%–69%Missing two or more DSM-5-TR diagnoses, and ICD-10, or reimbursement codes assigned to the scenario; contains 4+ errors, or response is missing. Missing Justification.

17 to >15.0 ptsGood 80%–89%The response accurately explains what pertinent documentation information is required to support DSM-5-TR diagnoses and ICD-10 coding.

15 to >13.0 ptsFair 70%–79%The response somewhat vaguely or inaccurately explains what pertinent documentation information is required to support DSM-5-TR diagnoses and ICD-10 coding.

13 to >0 ptsPoor 0%–69%The response vaguely or inaccurately explains what pertinent documentation information is required to support DSM-5-TR diagnoses and ICD-10 coding, or the explanation is incomplete or missing.

13 to >11.0 ptsGood 80%–89%The response accurately identifies the pertinent missing information from the case scenario and identifies what additional information would narrow coding and billing options. Discusses at least 4-6 missing components of documentation.

11 to >10.0 ptsFair 70%–79%The response somewhat vaguely or inaccurately identifies the pertinent missing information from the case scenario and identifies what additional information would narrow coding and billing options. Discusses at least 2-3 missing components of documentation.

10 to >0 ptsPoor 0%–69%The response vaguely or inaccurately identifies the pertinent missing information from the case scenario or partially identifies what additional information would narrow coding and billing options, or this information is incomplete or missing. Discusses 1 or no conversation of missing components of documentation.

13 to >11.0 ptsGood 80%–89%The response accurately explains but is not concise in explanation of legal and ethical dilemmas with 2 strategy proposals for future clinical practice.

11 to >10.0 ptsFair 70%–79%The response somewhat vaguely or inaccurately explains legal and ethical dilemmas with 1 strategy proposal for future clinical practice.

10 to >0 ptsPoor 0%–69%The response does not or vaguely, inaccurately explains either legal or ethical (not both) dilemmas with 1 or missing strategy proposals for future clinical practice.

4 to >3.5 ptsGood 80%–89%Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time…. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive.

3.5 to >3.0 ptsFair 70%–79%Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time…. Purpose, introduction, and conclusion of the assignment are vague or off topic.

3 to >0 ptsPoor 0%–69%Paragraphs and sentences follow writing standards for flow, continuity, and clarity <60% of the time…. Purpose statement, introduction, and conclusion were not provided.

13 to >11.0 ptsGood 80%–89%The response accurately explains how to improve documentation to support coding and billing for maximum reimbursement.

11 to >10.0 ptsFair 70%–79%The response somewhat vaguely or inaccurately explains how to improve documentation to support coding and billing for maximum reimbursement.

10 to >0 ptsPoor 0%–69%The response vaguely or inaccurately explains how to improve documentation to support coding and billing for maximum reimbursement, or response may be incomplete or missing.

4 to >3.5 ptsGood 80%–89%Contains 1-2 grammar, spelling, and punctuation errors

3.5 to >3.0 ptsFair 70%–79%Contains 3-4 grammar, spelling, and punctuation errors

3 to >0 ptsPoor 0%–69%Contains five or more grammar, spelling, and punctuation errors that interfere with the reader’s understanding

4 to >3.5 ptsGood 80%–89%Contains 1-2 APA format errors

3.5 to >3.0 ptsFair 70%–79%Contains 3-4 APA format errors

3 to >0 ptsPoor 0%–69%Contains five or more APA format errors