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1. Evaluation And Management (E/M) Homework
Evaluation And Management (E/M) HomeworkEvaluation And Management (E/M)
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. 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.Evaluation And Management (E/M)
HomeworkDiagnostic Screening Results Screen of symptoms in the past 2 weeks:PHQ 9 = 0
with symptoms rated as no difficulty in functioningInterpretation of Total ScoreTotal Score
Depression Severity 1-4 Minimal depression 5-9 Mild depression 10-14 Moderate

2. depression 15-19 Moderately severe depression 20-27 Severe depressionGAD 7 = 2 with
symptoms rated as no difficulty in functioningInterpreting the Total Score:Total Score
Interpretation ?10 Possible diagnosis of GAD; confirm by further evaluation 5 Mild
Anxiety 10 Moderate anxiety 15 Severe anxietyMDQ screen negativePCL-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 drink socially Cannabis NORDER NOW FOR CUSTOMIZED,
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