- The document describes a case study of a 25-year-old Russian female seeking a psychiatric evaluation with a history of PTSD, ADHD, and substance abuse disorder. - She reports ongoing symptoms of irritability, difficulty concentrating, nightmares, isolation, and missed work. - Screening assessments indicate minimal depression and anxiety. The diagnostic impression is PTSD and ADHD. - The treatment plan includes increasing antidepressant medication and continuing ADHD medication with medication management, therapy referral, and safety planning.

1. DSM-5 and ICD-10 coding Homework
DSM-5 and ICD-10 coding HomeworkDSM-5 and ICD-10 coding HomeworkAssign 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 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 coding and billing for maximum
reimbursement.ORDER NOW FOR CUSTOMIZED, PLAGIARISM-FREE PAPERSUse 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 InformationIdentification was verified by stating of their name and
date of birth. Time spent for evaluation: 0900am-0957amChief Complaint“My other
provider retired. I don’t think I’m doing so well.”HPI25 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. DSM-5 and ICD-10 coding HomeworkDiagnostic Screening
ResultsScreen 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

2. 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 32Past Psychiatric and Substance Use
TreatmentEntered 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 recordsSubstance Use HistoryHave 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
drink socially Cannabis N Cocaine Y last use 2015 Prescription stimulants Y last use 2015
Methamphetamine N Inhalants N Sedative/sleeping pills N Hallucinogens N Street Opioids
N Prescription opioids N Other: specify (spice, K2, bath salts, etc.) Y reports one-time
ecstasy use in 2015 Any history of substance related: Blackouts: + Tremors: – DUI: – D/T’s:
– Seizures: – Longest sobriety reported since 2015—stayed sober maintaining sponsor,
sober friends, and meetingsPsychosocial HistoryClient was raised by adoptive parents since
age 6; from Russian orphanage. She has unknown siblings. She is single; has no children.
Employed at local tanning bed salon Education: High School Diploma Denied current legal
issues.Suicide / HOmicide Risk AssessmentRISK FACTORS FOR SUICIDE: Suicidal Ideas or
plans – no Suicide gestures in past – no Psychiatric diagnosis – yes Physical Illness (chronic,
medical) – no Childhood trauma – yes Cognition not intact – no system – yes
Unemployment – no Stressful life events – yes Physical abuse – yes Sexual abuse – yes
Family history of suicide – unknown Family history of mental illness – unknown
Hopelessness – no Gender – female Marital status – single White race Access to means
Substance abuse – in remission PROTECTIVE FACTORS FOR SUICIDE: Absence of psychosis
– yes Access to adequate health care – yes Advice & help seeking – yes
Resourcefulness/Survival skills – yes Children – no Sense of responsibility – yes Pregnancy
– no; last menses one week ago, has Norplant Spirituality – yes Life satisfaction – “fair
amount” Positive coping skills – yes Positive social – yes Positive therapeutic relationship
– yes Future oriented – yes Suicide Inquiry: Denies active suicidal ideations, intentions, or
plans. Denies recent self-harm behavior. Talks futuristically. Denied history of
suicidal/homicidal ideation/gestures; denied history of self-mutilation behaviors Global
Suicide Risk Assessment: The client is found to be at low risk of suicide or violence,
however, risk of lethality increased under context of drugs/alcohol. No required SAFETY
PLAN related to low riskMental Status ExaminationShe is a 25 yo Russian female who looks
her stated age. She is cooperative with examiner. She is neatly groomed and clean, dressed
appropriately. There is mild psychomotor restlessness. Her speech is clear, coherent,
normal in volume and tone, has strong cultural accent. Her thought process is ruminative.
There is no evidence of looseness of association or flight of ideas. Her mood is anxious,
mildly irritable, and her affect appropriate to her mood. She was smiling at times in an

3. appropriate manner. She denies any auditory or visual hallucinations. There is no evidence
of any delusional thinking. She denies any current suicidal or homicidal ideation.
Cognitively, She is alert and oriented to all spheres. Her recent and remote memory is intact.
Her concentration is fair. Her insight is good.Clinical ImpressionClient is a 25 yo Russian
female who presents with history of treatment for PTSD, ADHD, Stimulant use Disorder, in
remission. Moods are anxious and irritable. She has ongoing reported symptoms of re-
experiencing, avoidance, and hyperarousal of her past trauma experiences; ongoing
subsyndromal symptoms related to her past ADHD diagnosis and exacerbated by her PTSD
diagnosis. She denied vegetative symptoms of depression, no evident mania/hypomania, no
psychosis, denied anxiety symptoms. Denied current cravings for drugs/alcohol, exhibits no
withdrawal symptoms, has somatic concerns of GI upset and headaches. At the time of
disposition, the client adamantly denies SI/HI ideations, plans or intent and has the ability
to determine right from wrong, and can anticipate the potential consequences of behaviors
and actions. She is a low risk for self-harm based on her current clinical presentation and
her risk and protective factors. DSM-5 and ICD-10 coding HomeworkDiagnostic
Impression[Student to provide DSM-5 and ICD-10 coding] Double click inside this text box
to add/edit text. Delete placeholder text when you add your answers.Treatment
PlanMedication: Increase fluoxetine 40mg po daily for PTSD #30 1 RF Continue with
atomoxetine 80mg po daily for ADHD. #30 1 RF Instructed to call and report any adverse
reactions. Future Plan: monitor for decrease re-experiencing, hyperarousal, and avoidance
symptoms; monitor for improved concentration, less mistakes, less forgetful Education:
Risks and benefits of medications are discussed including non-treatment. Potential side
effects of medications discussed. Verbal informed consent obtained. Not to drive or operate
dangerous machinery if feeling sedated. Not to stop medication abruptly without discussing
with providers. Discussed risks of mixing medications with OTC drugs, herbal,
alcohol/illegal drugs. Instructed to avoid this practice. Praised and Encouraged ongoing
abstinence. Maintain system, sponsors, and meetings. Discussed how drugs/ETOH affects
mental health, physical health, sleep architecture. Patient was educated about therapy and
services of the MHC including emergent care. Referral was sent via email to therapy team
for PET treatment. Patient has emergency numbers: Emergency Services 911, the national
Crisis Line 800-273-TALK, the MHC Crisis Clinic. Patient was instructed to go to nearest ER
or call 911 if they become actively suicidal and/or homicidal. Time allowed for questions
and answers provided. Provided ive listening. Patient appeared to understand discussion
and appears to have capacity for decision making via verbal conversation. RTC in 30 days
Follow up with PCP for GI upset and headaches, reviewed PCP history and physical dated
one week ago and include lab results Patient is amenable with this plan and agrees to follow
treatment regimen as discussed.