The Assignment Assign DSM-5 and ICD-10 codes to services based upon the patient case scenario. Then, in 1–2 pages address the following. You may add your narrative answers to these questions to the bottom of the case scenario document and submit altogether as one document. Explain what pertinent information, generally, is required in documentation to support DSM-5 and 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. Instructions Use the following case template to complete Week 2   Assignment 1. On page 5, assign DSM-5 and 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. Identifying Information Identification was verified by stating of their name and     date of birth. Time spent for evaluation: 0900am-0957am Chief Complaint “My other provider retired. I don’t think I’m doing so     well.” HPI 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. Diagnostic Screening Results 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 Past Psychiatric and Substance Use Treatment · 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 Substance Use History 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 dr…

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