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The patient in the case scenario, a 29-year-old male with a chief complaint of “stomach pain,” requires evaluation and management (E/M) services to diagnose and address his condition. For initial DSM-5-TR coding, F45.8 would be appropriate, given that the patient was symptomatic and had no prior diagnosis. As for ICD-10 coding, K29.2 would be suitable, given that it pertains to abdominal pain, the primary symptom experienced by the patient in this case.

When it comes to the documentation required to support DSM-5-TR and ICD-10 coding, pertinent information needed will include elements such as medical history, review of systems, physical examination findings, mental health assessment results if applicable, diagnoses or differential diagnoses being considered, as well as relevant test results or other diagnostic studies. In addition, documentation should contain comprehensive details about how the provider arrived at their diagnosis and plan for treatment for maximum reimbursement by insurance carriers. EVALUATION AND MANAGEMENT (E/M)

The case scenario provided needs to contain more information to support DSM-5-TR and ICD-10 coding because there are no details regarding what medical history was taken from the patient during his visit nor any documents about the review of systems or physical exam findings. Furthermore, there is no indication of any mental health assessment conducted or relevant test results used to rule out any necessary differential diagnoses or arrive at a specific diagnosis for the patient’s condition. EVALUATION AND MANAGEMENT (E/M)

To improve documentation to support coding and billing for maximum reimbursement, providers must ensure that they are accurately capturing all pertinent information related to the patient’s visit when documenting their encounter with them, including medical history taking notes; review of systems; assessments conducted; tests performed; impressions based on collected data; diagnoses made; plans formulated; medications prescribed; follow up recommendations; referrals made, etc., so that insurance payers can better understand the nature and complexity of work done by healthcare providers. Providers should also ensure that they correctly assign proper codes with descriptive modifiers where necessary so that their claims will be processed faster with minimum denials or delays resulting in optimal reimbursements. EVALUATION AND MANAGEMENT (E/M)



Assign DSM-5-TR 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-TR 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.

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