Week 2- Evaluation and Management
College of Nursing-PMHNP, Walden University
NRNP 6675: PMHNP Care Across the Lifespan II
September 13, 2021
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Introduction
The International Classification of Diseases, 10th revision (ICD 10) or the Diagnostic
and Statistical Manual of Mental Disorders, 5th edition (DSM-5) are used to categorize
medical problems (DSM-5). Both the World Health Organization (WHO) and the US accept
them as the only two internationally recognized sickness classification systems. The DSM-5
is primarily used to diagnose mental illnesses such as addiction, depression, eating disorders,
and schizophrenia. ICD-1O is a HIPAA-approved diagnosis code for musculoskeletal,
respiratory, gastrointestinal, and genitourinary diseases. This paper describes what
information is needed in documentation to enable DSM-5 and ICD-10 coding, then analyzes
a case scenario to see what information is lacking and how to fix it.
Pertinent Information Required in Documentation to Support DSM-5 and ICD-
10 coding
Even though both DSM-5 and ICD-10 are widely used to define illnesses, they may or
may not be utilized at the same time due to a number of variances. Unlike DSM-5, which is
solely utilized for mental diseases, ICD-10 is only used for inpatient claims after a diagnosis
has been made (Healthcare BPO, 2021). ICD-10 also distinguishes between dependency and
substance abuse, although DSM-5 does not. General pertinent information about a patient's
previous psychiatric and substance use, abuse, and treatment, psychosocial history,
suicide/homicide risk assessment, mental status examination, clinical impression, abnormal
findings, external causes of injury, social circumstances, and complaints is required for DSM-
5 and ICD-10 coding to be supported in documentation (Nathan, 2021)
Pertinent Information missing from the given case study
The DSM-5 is primarily concerned with assisting healthcare providers in correctly
classifying and diagnosing disorders (Best Notes, 2019). On the other side, the ICD-10 is
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primarily intended to assist with billing and payments. The patient in this instance is a 25-
year-old Russian woman who was recommended for psychiatric examination by her retiring
practitioner for stimulant use problem, PTSD, ADHD, and is currently in remission. The
patient's past psychiatric and substance use, abuse and treatment, psychosocial history,
suicide/homicide risk assessment, mental status evaluation, and clinical impression have all
been included in the case scenario. However, there is no documentation of the patient's
aberrant findings, external causes of harm, social circumstances, or complaints. Including
information about these four in the documentation will assist in narrowing the coding and
billing possibilities.
How to improve the documentation to support coding and billing for maximum reimbursement
Filing accurate claims that fulfill all reporting criteria and keeping track of denials are
critical to increasing income for a healthcare business. There are several key techniques that
can be implemented to improve documentation in order to assist coding and invoicing for
maximum reimbursement. Physicians and other staff members at healthcare facilities should
be educated on coding. When a coder assists healthcare practitioners in writing down
information and comparing notes, the physicians will learn that they have been ignoring some
critical information in their notes, especially when reading x-rays and reviewing lab data.
Facilities for health care should endeavor to stay current on coding resources and regulations.
It's also a good idea to stay up to date on coding materials and laws. Finally, before
attempting to code, read all provider and clinician notes thoroughly (Neeraj, 2016).
Conclusion
The DSM–5 is a guidebook for assessing and diagnosing mental disorders; it does not
provide information or treatment suggestions for any disorder. However, like with any
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medical problem, getting an accurate diagnosis is the first step toward being able to treat it
correctly, and mental disorders are no exception. DSM–5 will also be helpful in measuring the
effectiveness of treatment, as dimensional assessments will assist clinicians in assessing
changes in severity levels as a response to treatment. The crucial thing to remember is
that DSM-V aids doctors in more precisely diagnosing behavioral health conditions. ICD-10,
on the other hand, aids billing personnel in accurately coding and billing. Because of these
distinctions, an EHR system for a behavioral health provider should have both types of
coding. The DSM is developed by a single country professional association, whereas the
ICD is generated by a worldwide health body with a constitutional public health objective.
The major goal of the WHO's mental and behavioral disorders classification is to assist
countries in lowering the illness burden associated with mental disorders. The APA's purpose
in establishing DSM–5 was to create an evidence-based guidebook that would aid doctors in
accurately diagnosing mental disorders. The inclusion of a diagnosis in the DSM–5 was
based on thorough assessment of scientific developments in the disorder's study, as well as
the combined clinical knowledge of specialists in the field.
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References
Best Notes. (2019). How ICD-10 and DSM-V Work Together in an EHR.
Healthcare BPO. (2021). A complete guide to key differences between ICD-10 and DSM-5.
Outsource 2 India. https://www.outsource2india.com/Healthcare/articles/key-
differences- between-icd-10-dsm-5.asp
Nathan, Boyd. (2021). Diagnostic Codes: DSM-5 vs. ICD-10. Kasa. https://kasa-
solutions.com/diagnostic-codes-dsm-5-vs-icd-10/
Neeraj, Jan. (2016). Six Strategies for improving coding and reimbursement. M-
subscribe.com.
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