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Detailed Guidelines for Week 2 Assignment 1 – Psychiatric Evaluation Case

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1. Preparing the Case Documentation

• Verify all identifying information (name, DOB, date/time of evaluation).

• Record the chief complaint exactly as stated by the patient.

• Summarize the HPI (History of Present Illness), including:

  • Symptom onset, duration, severity, and triggers.

  • Medications, dosages, and recent changes.

  • Relevant functional impairments (sleep, appetite, social, occupational).

• Include past psychiatric history, hospitalizations, medication trials, and treatments.

• Include substance use history with frequency, quantity, and last use.

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2. Mental Status Examination (MSE)

• Document each domain:

  • Appearance (hygiene, dress, age-appropriate)

  • Behavior and psychomotor activity (restlessness, agitation, retardation)

  • Speech (rate, volume, coherence)

  • Mood and affect (e.g., anxious, irritable)

  • Thought process (logical, coherent, goal-directed)

  • Thought content (delusions, obsessions, suicidal ideation)

  • Perception (hallucinations)

  • Cognition (orientation, attention, memory)

  • Insight and judgment

• Be detailed but concise; this supports diagnosis and billing.

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3. Assigning DSM-5-TR Diagnoses

• Review the HPI and MSE.

• Identify primary disorders (e.g., Major Depressive Disorder, Panic Disorder).

• Include specifier if relevant (e.g., moderate, recurrent).

• Rule out conditions not present (e.g., bipolar, psychosis, OCD).

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4. Assigning ICD-10 Codes

• Match each DSM-5-TR diagnosis with the correct ICD-10 code.

• Double-check accuracy in the ICD-10 manual or online database.

• Ensure accuracy and specificity, e.g., F33.1 for Major Depressive Disorder, Recurrent, Moderate.

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5. Choosing a Billing Code

• Determine if the session is a diagnostic evaluation only (CPT 90791) or includes psychotherapy (90792).

• Use the time and content of the session to justify the code.

• Document thoroughly: what was assessed, clinical decision-making, and treatment planning.

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6. Supporting Documentation

Include information that supports your diagnosis and billing:

• Duration and type of services provided (time-based documentation).

• Patient’s reported symptoms and functional impairment.

• Mental status exam findings.

• Past psychiatric and medical history.

• Treatment plan (medications, follow-up, crisis planning).

• Risk assessment (suicide/homicide).

• Clinical decision-making notes and rationale for treatment choices.

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7. Identifying Missing Documentation

Look for gaps that could affect coding or reimbursement:

• Family psychiatric history

• Medication allergies/intolerances

• Detailed psychosocial stressors

• Physical comorbidities

• Insight and judgment assessment

• Cognitive evaluation

• Full substance use history and screening results

• Laboratory or diagnostic results

• Documentation of patient consent for treatment

• Functional status (work, social, daily living)

• Legal history

• Previous therapy or counseling interventions

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8. Legal and Ethical Considerations

• Avoid upcoding (billing for services not rendered or more intensive than provided).

• Avoid overbilling or fraudulent claims.

• Strategies to maintain ethical practice:

  • Keep thorough and accurate documentation for each session.

  • Regularly audit coding and billing procedures.

  • Stay updated with compliance guidelines (CMS, HIPAA).

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9. Tips for Improving Documentation

• Include specific clinical details that justify diagnosis and treatment.

• Document time spent, interventions, and patient education.

• Use standardized assessment tools (e.g., Severity Measure for Panic Disorder) with scores.

• Keep a clear flow from history → assessment → plan.

• Use structured templates or checklists to ensure no critical element is missed.

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10. How to Structure Your Narrative Answers

• Paragraph 1: Justify DSM-5-TR diagnoses and ICD-10 codes.

• Paragraph 2: Choose and justify the CPT billing code.

• Paragraph 3: List supporting documentation and highlight missing elements.

• Paragraph 4: Discuss legal/ethical considerations and propose strategies.

• Paragraph 5: Recommend improvements to documentation for accurate coding and maximum reimbursement.