The document outlines an assignment to assign DSM-5 and ICD-10 codes based on a patient case scenario involving a 25-year-old Russian female with PTSD, ADHD, and a history of stimulant use disorder. The assignment requires a discussion on essential documentation for coding, identifying any missing information that could assist in refining coding and billing options, and recommendations for improving documentation to enhance reimbursement. The case details include the patient's psychiatric evaluation, risk assessments, and treatment plans pertinent for accurate coding.

1. 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

2. 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

3. 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

4. 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

5. 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

6. 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

7. Prescription stimulants
Y
last use 2015
Methamphetamine
N
Inhalants
N
Sedative/sleeping pills
N
Hallucinogens

8. 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: -

9. · DUI: -
· D/T's: -
· Seizures: -
Longest sobriety reported since 2015—stayed sober
maintaining sponsor, sober friends, and meetings
Psychosocial History
Client 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 Assessment
RISK FACTORS FOR SUICIDE:
· Suicidal Ideas or plans - no
· Suicide gestures in past - no

10. · Psychiatric diagnosis - yes
· Physical Illness (chronic, medical) - no
· Childhood trauma - yes
· Cognition not intact - no
· Support 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:

11. · 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 support - 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.

12. No required SAFETY PLAN related to low risk
Mental Status Examination
She 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 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 Impression
Client 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

13. 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.
Diagnostic 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 Plan
1) Medication:
· Increase fluoxetine 40mg po daily for PTSD #30 1 RF
· Continue with atomoxetine 80mg po daily for ADHD. #30 1

14. 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
2) 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 support system, sponsors, and meetings.
Discussed how drugs/ETOH affects mental health, physical
health, sleep architecture.
3) Patient was educated about therapy and services of the
MHC including emergent care. Referral was sent via email to
therapy team for PET treatment.

15. 4) 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.
5) Time allowed for questions and answers provided.
Provided supportive listening. Patient appeared to understand
discussion and appears to have capacity for decision making
via verbal conversation.
6) RTC in 30 days
7) 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.
Narrative Answers
[In 1-2 pages, address the following:
· 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

16. 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.]
Add your answers here. Delete instructions and placeholder
text when you add your answers.