EVALUATION AND MANAGEMENT (E/M)

Insurance coding and billing is complex, but it boils down to how to accurately apply a code, or CPT (current procedural terminology), to the service that you provided. The payer then reimburses the service at a certain rate. As a provider, you will have to understand what codes to use and what documentation is necessary to support coding.

For this Assignment, you will review evaluation and management (E/M) documentation for a case study patient. You will analyze the documentation to formulate DSM-5-TR diagnoses and ICD-10 coding. You will formulate a billing code for reimbursement of the case study. You will consider legal and ethical considerations for coding and billing. You will analyze and consider the documentation necessary to support accurate billing and coding procedures.

RESOURCES

Be sure to review the Learning Resources before completing this activity. Click the weekly resources link to access the resources.

WEEKLY RESOURCES

TO PREPARE

· Review this week’s Learning Resources on coding, billing, reimbursement.

· Review the E/M patient case scenario provided.

THE ASSIGNMENT

· Assign DSM-5-TR diagnoses, ICD-10, and reimbursement codes to services based on the patient case scenario.

Then, in 2-3 pages, address the following. You will add your narrative answers to these questions to the bottom of the case scenario document and submit them altogether as one document.

· What reimbursement billing code would you use for this session? Provide your justification for using this billing code.

· Explain what pertinent information is required in documentation to support your chosen DSM-5-TR diagnoses, ICD-10 coding, and billing code.

· Explain what pertinent documentation is missing from the case scenario and what other information would be helpful to narrow your coding and billing options. (There are at least 12 missing pertinent components of documentation).

· Discuss legal and ethical dilemmas related to overbilling, upcoding, and fraudulent practices. Propose 2 strategies for promoting legal and ethical coding and billing practices within your future clinical roles.

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

· American Psychiatric Association. (2024). CPT coding and reimbursementLinks to an external site. . https://www.psychiatry.org/psychiatrists/practice/practice-management/coding-and-reimbursement

· American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders. Section II. In Diagnostic and statistical manual of mental disorders Links to an external site. (5th ed., text rev.). https://go.openathens.net/redirector/waldenu.edu?url=https://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425787

· Buppert, C. (2021). Nurse practitioner’s business practice and legal guide (7th ed.). Jones & Bartlett Learning.

· Chapter 9, “Reimbursement for Nurse Practitioner Services”

· Centers for Medicare & Medicaid Services. (2023). Medicare & mental health coverageLinks to an external site. . https://www.cms.gov/files/document/mln1986542-medicare-mental-health-coverage.pdf

· Centers for Medicare & Medicaid Services. (2023). Your billing responsibilities Links to an external site. . https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/ProviderServices/Your-Billing-Responsibilities

· DeNisco, S. M. (2023). Role development for the nurse practitioner (3rd ed.). Jones & Bartlett Learning.

· Chapter 17, “Reimbursement for Nurse Practitioner Services” (pp. 403-427)

· Chapter 14, “Concepts and Challenges of the Professional Nurse Practitioner” (pp. 351-362)

· Chapter 15, “Health Policy and the Nurse Practitioner” (pp. 367-384)

· Chapter 16, “Mentoring and Lifelong Learning” (pp. 389-399)

· Walden University Academic Skills Center. (2017). Developing SMART goals Links to an external site. . https://academicguides.waldenu.edu/ld.php?content_id=51901492

· Zakhari, R. (2021). The psychiatric-mental health nurse practitioner certification review manual . Springer Publishing Company.

· Chapter 4 “Neuroanatomy, Physiology, and Mental Illness”

Guidelines for the Assignment

1. DSM-5-TR & ICD-10 Diagnoses

• Review the case scenario carefully.

• Assign the primary DSM-5-TR diagnosis (e.g., Major Depressive Disorder, Generalized Anxiety Disorder, PTSD, etc.).

• Assign any secondary diagnoses (comorbidities if present).

• Match each DSM-5-TR diagnosis with the appropriate ICD-10 code (use DSM-5-TR Section II as a reference).

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2. Reimbursement Billing Code

• Select the correct E/M CPT code (e.g., 99213, 99214, 99215, 90791 for psychiatric evaluation, or 90833 add-on for psychotherapy if applicable).

• Justify your choice based on:

  • Complexity of medical decision-making.

  • Time spent with the patient.

  • Documentation provided.

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3. Documentation Requirements

• Explain what documentation is necessary to support billing and coding:

  • Chief complaint

  • History of present illness (HPI)

  • Review of systems (ROS)

  • Past psychiatric/medical history

  • Medications & allergies

  • Family/social history

  • Mental status exam (MSE)

  • Risk assessment (suicidality, violence, substance use)

  • Treatment plan

  • Patient education & informed consent

  • Time spent in session

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4. Missing Documentation (≥12 components)

• Identify what is not included in the case study but should be documented:

  • Vital signs

  • Functional impairment description

  • Substance use screening

  • Trauma history

  • Medication adherence & side effects

  • Lab/imaging if relevant

  • Collateral information

  • Protective factors

  • Patient goals/preferences

  • Informed consent

  • Billing justification

  • Follow-up plan

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5. Legal & Ethical Considerations

• Define overbilling, upcoding, unbundling, and fraudulent claims.

• Discuss risks: fines, loss of licensure, criminal charges, ethical violations.

• Propose 2 strategies for ethical practice:

  • Ongoing coding/billing training.

  • Peer or compliance audits within the organization.

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6. Improving Documentation for Reimbursement

• Stress the need for:

  • Clear, detailed notes matching the DSM-5-TR/ICD-10 diagnoses.

  • Linking treatment plan directly to documented symptoms.

  • Accurate time documentation for E/M code justification.

  • Using standardized templates (SOAP, DAP, EHR smart forms).

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Required References (sample to cite in APA 7th)

• American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://dsm.psychiatryonline.org/

• Centers for Medicare & Medicaid Services. (2023). Medicare & mental health coverage. https://www.cms.gov/files/document/mln1986542-medicare-mental-health-coverage.pdf

• Buppert, C. (2021). Nurse practitioner’s business practice and legal guide (7th ed.). Jones & Bartlett Learning.

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Deliverables:

• Add DSM-5-TR, ICD-10, and CPT codes at the top/beginning of the case scenario file.

• Attach your 2–3 page narrative below the case scenario (per instructions).

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