Evaluation And Management Of Improving Coding And Reimbursement Discussion

Evaluation And Management Of Improving Coding And Reimbursement Discussion

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Evaluation and management is a process of assessing the condition of a patient, formulating an appropriate diagnosis as well as establishing an appropriate treatment plan to meet the needs of that specific patient. In terms of medical coding and billing, evaluation and management codes are used distinguish the complexity of patient visits to guide reimbursement. Some of the common evaluation and management services range from routine and minor office visits to more complex services such as psychiatric assessments. Usually, the coding is applied to new and established patients and the E/M codes must be filled by a qualified healthcare provider for reimbursement by Medicaid, Medicare and other insurance companies. The coding should be done with a lot of precision and accuracy to avoid instances of denied or delayed reimbursements (Burks et al., 2022)Evaluation And Management Of Improving Coding And Reimbursement Discussion.


Explain what pertinent information, generally, is required in documentation to support DSM-5 and ICD-10 coding.

DSM-5-TR and ICD-10 coding is essential for accurate and effective healthcare management, billing, and communication among healthcare providers. Proper documentation helps to ensures accurate coding, billing, and communication between healthcare professionals which h helps to improve patient outcomes and enhance reimbursement (Abbasi-Feinberg, 2020). Effective documentation can also help support continuity of care across different healthcare facilities and hence improve healthcare outcomes. Some of the pertinent information that is required in documentation to support DSM-5 coding includes patient demographics as well as the chief complaint. The patient information such as the name, gender and age must be appropriately included in the documentation.  Further, there must be a concise description of the reason for seeking help. Also, the history of present illness and the past psychiatric history must be included for proper documentation. Other information that should be included includes severity and functional assessment as well as the treatment plan.

In the case of ICD-10 documentation, some of the pertinent information that should be included includes an accurate identification of the diagnosis, causal relationships between conditions if applicable as well as the nature of the condition i.e., acute or chronic. Also, details about ongoing treatment and management of the condition should be included.

Explain what pertinent documentation is missing from the case scenario, and what other information would be helpful to narrow your coding and billing options.

While the patient mentions a history of being raped during a house burglary at age 19 there is need to provide further details about the nature of this trauma, some of its impact as well as subsequent treatments or therapies. In addition, the patient reports a history of stimulant and cocaine abuse that is leading to a residential treatment in 2015 however; there is no information about the duration of the substance use disorder, the specific substances used or the factors contributing to remission.

Also, the patient states that she has difficulties at work that include missed days, problems in concentrating and irritability. It would be important to document how the symptoms affect her job performance or the relationship with other co-workers. Other pertinent information that is missing includes the reasons for discontinuing some medications, side effects experienced as well as successful treatments. Evaluation And Management Of Improving Coding And Reimbursement Discussion

Finally, explain how to improve documentation to support coding and billing for maximum reimbursement

To improve documentation to support billing and coding, one must use a specific and suitable language when describing the patient behaviors and symptoms.  Also, the provider’s clinical impression must be clearly documented. Also, there is need to conduct a thorough review of systems to capture relevant symptoms. One must also ensure that the documentation supports the medical necessity of the services provided. Also, consider reading provider or clinician notes fully before coding (Hughes, 2020)Evaluation And Management Of Improving Coding And Reimbursement Discussion.


Abbasi-Feinberg, F. (2020). Telemedicine coding and reimbursement-current and future trends. Sleep Medicine Clinics15(3), 417-429.

Burks, K., Shields, J., Evans, J., Plumley, J., Gerlach, J., & Flesher, S. (2022). A systematic review of outpatient billing practices. SAGE Open Medicine10, 20503121221099021.

Hughes, S. (2020, February 23). Six strategies for improving coding and reimbursement. Coronis. Evaluation And Management Of Improving Coding And Reimbursement Discussion

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