Evaluation and Management (E/M)

Insurance coding and billing is complex, but it boils down to how to accurately apply a code, or CPT (current procedural terminology), to the service that you provided. The payer then reimburses the service at a certain rate. As a provider, you will have to understand what codes to use and what documentation is necessary to support coding.

For this Assignment, you will review evaluation and management (E/M) documentation for a case study patient. You will analyze the documentation to formulate DSM-5-TR diagnoses and ICD-10 coding. You will formulate a billing code for reimbursement of the case study. You will consider legal and ethical considerations for coding and billing. You will analyze and consider the documentation necessary to support accurate billing and coding procedures.

To Prepare

• Review this week’s Learning Resources on coding, billing, reimbursement.
• Review the E/M patient case scenario provided.(PLEASE SEE ATTACHED FILE FOR CASE SCENARIO)

The Assignment

• Assign DSM-5-TR diagnoses, ICD-10, and reimbursement codes to services based on the patient case scenario.

Then, in 2-3 pages, address the following. You will add your narrative answers to these questions to the bottom of the case scenario document and submit them altogether as one document.

• What reimbursement billing code would you use for this session? Provide your justification for using this billing code.
• Explain what pertinent information is required in documentation to support your chosen DSM-5-TR diagnoses, ICD-10 coding, and billing code.
• Explain what pertinent documentation is missing from the case scenario and what other information would be helpful to narrow your coding and billing options. (There are at least 12 missing pertinent components of documentation).
• Discuss legal and ethical dilemmas related to overbilling, upcoding, and fraudulent practices. Propose 2 strategies for promoting legal and ethical coding and billing practices within your future clinical roles.
• Finally, explain how to improve documentation to support coding and billing for maximum reimbursement.

Learning Resources

• American Psychiatric Association. (2024).CPT coding and reimbursementLinks to an external site..https://www.psychiatry.org/psychiatrists/practice/practice-management/coding-and-reimbursement
  
  
• American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders. Section II.InDiagnostic and statistical manual of mental disordersLinks to an external site.(5th ed., text rev.). https://go.openathens.net/redirector/waldenu.edu?url=https://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425787
  
  
• Buppert, C. (2021).Nurse practitioner’s business practice and legal guide(7th ed.). Jones & Bartlett Learning.
  • Chapter 9, “Reimbursement for Nurse Practitioner Services”
    
    
• Centers for Medicare & Medicaid Services. (2023).Medicare & mental health coverageLinks to an external site.. https://www.cms.gov/files/document/mln1986542-medicare-mental-health-coverage.pdf
  
  
• Centers for Medicare & Medicaid Services. (2023).Your billing responsibilitiesLinks to an external site.. https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/ProviderServices/Your-Billing-Responsibilities
  
  
  
• DeNisco, S. M. (2023).Role development for the nurse practitioner(3rd ed.). Jones & Bartlett Learning.
  • Chapter 17, “Reimbursement for Nurse Practitioner Services” (pp. 403-427)
  • Chapter 14, “Concepts and Challenges of the Professional Nurse Practitioner” (pp. 351-362)
  • Chapter 15, “Health Policy and the Nurse Practitioner” (pp. 367-384)
  • Chapter 16, “Mentoring and Lifelong Learning” (pp. 389-399)
• Walden University Academic Skills Center. (2017).Developing SMART goals Links to an external site.. https://academicguides.waldenu.edu/ld.php?content_id=51901492
  
  
• Zakhari, R. (2021).The psychiatric-mental health nurse practitioner certification review manual. Springer Publishing Company.
  • Chapter 4 “Neuroanatomy, Physiology, and Mental Illness”