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Evaluation and Management

Name

Institution affiliation

Date
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Evaluation and Management

Diagnostic Impression

DSM-V- Post Traumatic Stress disorder

ICD-10 coding- F43.1

Pertinent Information for Documentation of DSM-V and ICD-10 Coding

DSM-V is one of the considered effective methods of diagnosis. The criteria are used to

obtain an accurate diagnosis of mental health disorders. However, for an accurate diagnosis, the

health professional should obtain pertinent information from the patient both subjective and

objective. In the documentation, some of the pertinent information includes a detailed mental

status examination and diagnostic and laboratory tests. The information will be critical in

ensuring that the practitioner obtains an accurate diagnosis through the DSM-V criteria (Murphy

et al., 2018). Similarly, the information will also be pertinent to the ICD-10 coding. The coding

is essential in measuring the quality and billing of the health conditions in health care. Therefore,

obtaining pertinent information on the mental status examination and diagnostic tests will be

important in determining the billing or reimbursement procedures. The diagnostic tests are

important in determining some of the other infections or conditions that are causing the

symptoms. In such cases, it will be important to rule out some other conditions to arrive at a

relevant condition per the DSM-V criteria and determine the billing process.

Pertinent Information Missing from The Case

The provided cases outline significant pertinent information for the diagnosis of the

patient. However, some key information that could be helpful in the coding and billing process is

missing. Some of the missing information includes the character of the mentioned symptoms and

behaviors. For example, the patient mentioned to be easily frustrated and irritable, the
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practitioner should ask the patient to provide information on the aggravating factors of the

behaviors and symptoms. Understanding the aggravating and relieving factors could be an

important aspect of the diagnosis. The information on the character and nature of the impaired

functioning listed would be important. In the documentation, the results of the test reveal an

impaired function from the patient however it does not provide information on its nature.

Providing this information will be important in understanding the condition thus helping in the

diagnosis and billing procedures. On top of this, the documentation is missing information on

diagnostic tests and examinations done to the patient. According to McInnes et al. (2018), The

information is necessary since some infections could exhibit symptoms such as mental health

disorders. Therefore, diagnostic tests such as blood tests and thyroid function tests should be

provided to rule out other possible causes of the symptoms. The information will thus be

essential in providing a relevant and credible diagnosis that could translate to the coding and

billing processes.

Strategies to Improve Documentation

Given the significance of information in information the billing and DSM-V criteria,

there is a need to ensure critical documentation to ensure maximum reimbursements. Accurate

documentation is one of the ways of ensuring support of the DSM-V and ICD-10 procedures.

Accurate documentation ensures that the practitioner records the information in real-time

utilizing the available tools. Pine and Bossen (2020) explain that in most cases health facilities

have adopted a range of technologies that they use for documentation. Electronic health record

(EHR) is one of the commonly used documentation technologies to ensure efficiency and

accuracy in the health sector. For example, as noted by the Centers for Medicare and Medicaid
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Services (nd), it is recommended that the billing information should be obtained at the time the

service is provided.

Another strategy is ensuring keen and detailed objective information is obtained.

Information such as diagnostic tests and physical examination are crucial to the diagnosis

process. In this case, the information should be accurately documented to avoid judgment from

only the physical symptoms (Pine & Bossen, 2020). Tests are one of the ways of ensuring

accurate diagnosis for the patients to rule out different conditions. In this case, the information

should be provided adequately and documented. Therefore, the strategies used will be critical in

improving the documentation which ensures coding and billing for maximum reimbursements.
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References

Centers for Medicare and Medicaid Services (n.d). Your billing responsibilities.

https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/

ProviderServices/Your-Billing-Responsibilities

McInnes, M. D., Moher, D., Thombs, B. D., McGrath, T. A., Bossuyt, P. M., Clifford, T., ... &

Willis, B. H. (2018). Preferred reporting items for a systematic review and meta-analysis

of diagnostic test accuracy studies: the PRISMA-DTA statement. Jama, 319(4), 388-396.

Murphy, D., Glaser, K., Hayward, H., Eklund, H., Cadman, T., Findon, J., ... & Asherson, P.

(2018). Improving outcomes through better diagnosis: the effects of changes in DSM-V

on clinical diagnosis. In Crossing the divide: a longitudinal study of effective treatments

for people with autism and attention deficit hyperactivity disorder across the lifespan.

NIHR Journals Library.

Pine, K. H., & Bossen, C. (2020). Good organizational reasons for better medical records: The

data work of clinical documentation integrity specialists. Big Data & Society, 7(2),

2053951720965616.