Pathways Mental Health

Psychiatric Patient Evaluation

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.
Diagnostic Screening Results		Screen of symptoms in the past 2 weeks:  PHQ 9 = 0 with symptoms rated as no difficulty in 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 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 N Cocaine Y last use 2015 Prescription stimulants Y last use 2015 Methamphetamine N Inhalants N Sedative/sleeping pills N Hallucinogens 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:   – 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 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: 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. 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 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		Medication: Increase fluoxetine 40mg po daily for PTSD #30 1 RF Continue with atomoxetine 80mg po daily for ADHD. #30 1 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 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. Patient was educated about therapy and services of the MHC including emergent care. Referral was sent via email to therapy team for PET treatment. 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. 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. RTC in 30 days 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 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.

References

[Add APA-formatted citations for any sources you referenced]

Delete instructions and placeholder text when you add your citations.

Page | 2	Walden University, LLC

.MsftOfcThm_Accent1_lumMod_40_lumOff_60_Fill {
fill:#B1D1E3;
}

.MsftOfcThm_Accent1_lumMod_60_lumOff_40_Fill {
fill:#8ABAD4;
}

WK2 ASSIGNMENT

Assignment 1: 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 patient and perform a crosswalk of codes from DSM-5-TR to ICD-10. 

Photo Credit: Getty Images/Tetra images RF

To Prepare

· Review this week’s Learning Resources on coding, billing, reimbursement.

· Review the E/M patient case scenario provided.

The Assignment

· Assign DSM-5-TR 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-TR 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.   

By Day 7 of Week 2

Submit your Assignment. 

Submission and Grading Information

To submit your completed Assignment for review and grading, do the following:

Page | 2	Walden University, LLC

Rubric Detail

Select Grid View or List View to change the rubric’s layout.

Content

Name: NRNP_6675_Week2_Assignment1_Rubric

• Grid View
• List View

	Excellent 90%–100%	Good 80%–89%	Fair 70%–79%	Poor 0%–69%
In the E/M patient case scenario provided: • Assign DSM-5 and ICD-10 codes to services based upon the patient case scenario.	Points: Points Range: 18 (18%) – 20 (20%) DSM-5 and ICD-10 codes assigned to the scenario are correct, with no more than a minor error. Feedback:	Points: Points Range: 16 (16%) – 17 (17%) DSM-5 and ICD-10 codes assigned to the scenario are mostly correct, with a few minor errors. Feedback:	Points: Points Range: 14 (14%) – 15 (15%) DSM-5 and ICD-10 codes assigned to the scenario contain several errors. Feedback:	Points: Points Range: 0 (0%) – 13 (13%) DSM-5 and ICD-10 codes assigned to the scenario contain significant errors, or response is missing. Feedback:
In 1–2 pages, address the following: • Explain what pertinent information, generally, is required in documentation to support DSM-5 and ICD-10 coding.	Points: Points Range: 23 (23%) – 25 (25%) The response accurately and concisely explains what pertinent documentation information is required to support DSM-5 and ICD-10 coding. Feedback:	Points: Points Range: 20 (20%) – 22 (22%) The response accurately explains what pertinent documentation information is required to support DSM-5 and ICD-10 coding. Feedback:	Points: Points Range: 18 (18%) – 19 (19%) The response somewhat vaguely or inaccurately explains what pertinent documentation information is required to support DSM-5 and ICD-10 coding. Feedback:	Points: Points Range: 0 (0%) – 17 (17%) The response vaguely or inaccurately explains what pertinent documentation information is required to support DSM-5 and ICD-10 coding, or the explanation is incomplete or missing. Feedback:
• Explain what pertinent documentation is missing from the case scenario, and what other information would be helpful to narrow your coding and billing options.	Points: Points Range: 23 (23%) – 25 (25%) The response accurately and concisely identifies the pertinent misssing information from the case scenario and clearly identifies what additional information would narrow coding and billing options. Feedback:	Points: Points Range: 20 (20%) – 22 (22%) The response accurately identifies the pertinent misssing information from the case scenario and identifies what additional information would narrow coding and billing options. Feedback:	Points: Points Range: 18 (18%) – 19 (19%) The response somewhat vaguely or inaccurately identifies the pertinent misssing information from the case scenario and identifies what additional information would narrow coding and billing options. Feedback:	Points: Points Range: 0 (0%) – 17 (17%) The response vaguely or inaccurately identifies the pertinent misssing information from the case scenario or partially identifies what additional information would narrow coding and billing options, or this information is incomplete or missing. Feedback:
• Finally, explain how to improve documentation to support coding and billing for maximum reimbursement.	Points: Points Range: 14 (14%) – 15 (15%) The response accurately and concisely explains how to improve documentation to support coding and billing for maximum reimbursement. Feedback:	Points: Points Range: 12 (12%) – 13 (13%) The response accurately explains how to improve documentation to support coding and billing for maximum reimbursement. Feedback:	Points: Points Range: 11 (11%) – 11 (11%) The response somewhat vaguely or inaccurately explains how to improve documentation to support coding and billing for maximum reimbursement. Feedback:	Points: Points Range: 0 (0%) – 10 (10%) The response vaguely or inaccurately explains how to improve documentation to support coding and billing for maximum reimbursement, or response may be incomplete or missing. Feedback:
Written Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.	Points: Points Range: 5 (5%) – 5 (5%) Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria. Feedback:	Points: Points Range: 4 (4%) – 4 (4%) Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive. Feedback:	Points: Points Range: 3.5 (3.5%) – 3.5 (3.5%) Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment are vague or off topic. Feedback:	Points: Points Range: 0 (0%) – 3 (3%) Paragraphs and sentences follow writing standards for flow, continuity, and clarity <60% of the time. Purpose statement, introduction, and conclusion were not provided. Feedback:
Written Expression and Formatting – English Writing Standards: Correct grammar, mechanics, and proper punctuation	Points: Points Range: 5 (5%) – 5 (5%) Uses correct grammar, spelling, and punctuation with no errors Feedback:	Points: Points Range: 4 (4%) – 4 (4%) Contains 1-2 grammar, spelling, and punctuation errors Feedback:	Points: Points Range: 3.5 (3.5%) – 3.5 (3.5%) Contains 3-4 grammar, spelling, and punctuation errors Feedback:	Points: Points Range: 0 (0%) – 3 (3%) Contains five or more grammar, spelling, and punctuation errors that interfere with the reader’s understanding Feedback:
Written Expression and Formatting – The paper follows correct APA format for parenthetical/in-text citations and reference list.	Points: Points Range: 5 (5%) – 5 (5%) Uses correct APA format with no errors Feedback:	Points: Points Range: 4 (4%) – 4 (4%) Contains 1-2 APA format errors Feedback:	Points: Points Range: 3.5 (3.5%) – 3.5 (3.5%) Contains 3-4 APA format errors Feedback:	Points: Points Range: 0 (0%) – 3 (3%) Contains five or more APA format errors Feedback:

Show Descriptions

Show Feedback

In the E/M patient case scenario provided:

• Assign DSM-5 and ICD-10 codes to services based upon the patient case scenario.

—

Levels of Achievement:

Excellent

90%–100%
18 (18%) – 20 (20%)

DSM-5 and ICD-10 codes assigned to the scenario are correct, with no more than a minor error.

Good

80%–89%
16 (16%) – 17 (17%)

DSM-5 and ICD-10 codes assigned to the scenario are mostly correct, with a few minor errors.

Fair

70%–79%
14 (14%) – 15 (15%)

DSM-5 and ICD-10 codes assigned to the scenario contain several errors.

Poor

0%–69%
0 (0%) – 13 (13%)

DSM-5 and ICD-10 codes assigned to the scenario contain significant errors, or response is missing.

Feedback:

In 1–2 pages, address the following:

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

—

Levels of Achievement:

Excellent

90%–100%
23 (23%) – 25 (25%)

The response accurately and concisely explains what pertinent documentation information is required to support DSM-5 and ICD-10 coding.

Good

80%–89%
20 (20%) – 22 (22%)

The response accurately explains what pertinent documentation information is required to support DSM-5 and ICD-10 coding.

Fair

70%–79%
18 (18%) – 19 (19%)

The response somewhat vaguely or inaccurately explains what pertinent documentation information is required to support DSM-5 and ICD-10 coding.

Poor

0%–69%
0 (0%) – 17 (17%)

The response vaguely or inaccurately explains what pertinent documentation information is required to support DSM-5 and ICD-10 coding, or the explanation is incomplete or missing.

Feedback:

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

Levels of Achievement:

Excellent

90%–100%
23 (23%) – 25 (25%)

The response accurately and concisely identifies the pertinent misssing information from the case scenario and clearly identifies what additional information would narrow coding and billing options.

Good

80%–89%
20 (20%) – 22 (22%)

The response accurately identifies the pertinent misssing information from the case scenario and identifies what additional information would narrow coding and billing options.

Fair

70%–79%
18 (18%) – 19 (19%)

The response somewhat vaguely or inaccurately identifies the pertinent misssing information from the case scenario and identifies what additional information would narrow coding and billing options.

Poor

0%–69%
0 (0%) – 17 (17%)

The response vaguely or inaccurately identifies the pertinent misssing information from the case scenario or partially identifies what additional information would narrow coding and billing options, or this information is incomplete or missing.

Feedback:

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

Levels of Achievement:

Excellent

90%–100%
14 (14%) – 15 (15%)

The response accurately and concisely explains how to improve documentation to support coding and billing for maximum reimbursement.

Good

80%–89%
12 (12%) – 13 (13%)

The response accurately explains how to improve documentation to support coding and billing for maximum reimbursement.

Fair

70%–79%
11 (11%) – 11 (11%)

The response somewhat vaguely or inaccurately explains how to improve documentation to support coding and billing for maximum reimbursement.

Poor

0%–69%
0 (0%) – 10 (10%)

The response vaguely or inaccurately explains how to improve documentation to support coding and billing for maximum reimbursement, or response may be incomplete or missing.

Feedback:

Written Expression and Formatting – Paragraph Development and Organization:

Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.

—

Levels of Achievement:

Excellent

90%–100%
5 (5%) – 5 (5%)

Paragraphs and sentences follow writing standards for flow, continuity, and clarity.

A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.

Good

80%–89%
4 (4%) – 4 (4%)

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time.

Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive.

Fair

70%–79%
3.5 (3.5%) – 3.5 (3.5%)

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time.

Purpose, introduction, and conclusion of the assignment are vague or off topic.

Poor

0%–69%
0 (0%) – 3 (3%)

Paragraphs and sentences follow writing standards for flow, continuity, and clarity <60% of the time.

Purpose statement, introduction, and conclusion were not provided.

Feedback:

Written Expression and Formatting – English Writing Standards:

Correct grammar, mechanics, and proper punctuation

—

Levels of Achievement:

Excellent

90%–100%
5 (5%) – 5 (5%)

Uses correct grammar, spelling, and punctuation with no errors

Good

80%–89%
4 (4%) – 4 (4%)

Contains 1-2 grammar, spelling, and punctuation errors

Fair

70%–79%
3.5 (3.5%) – 3.5 (3.5%)

Contains 3-4 grammar, spelling, and punctuation errors

Poor

0%–69%
0 (0%) – 3 (3%)

Contains five or more grammar, spelling, and punctuation errors that interfere with the reader’s understanding

Feedback:

Written Expression and Formatting –

The paper follows correct APA format for parenthetical/in-text citations and reference list.

—

Levels of Achievement:

Excellent

90%–100%
5 (5%) – 5 (5%)

Uses correct APA format with no errors

Good

80%–89%
4 (4%) – 4 (4%)

Contains 1-2 APA format errors

Fair

70%–79%
3.5 (3.5%) – 3.5 (3.5%)

Contains 3-4 APA format errors

Poor

0%–69%
0 (0%) – 3 (3%)

Contains five or more APA format errors

Feedback:

Total Points: 100

Name: NRNP_6675_Week2_Assignment1_Rubric

Walden University

NRNP 6675: PMHNP Care Across the Lifespan II

• Week 2
• Introduction
• Resources
• Reminder
• Assignment 1
• Assignment 2
• Looking Ahead
• My Progress Tracker

NRNP 6675: PMHNP Care Across the Lifespan II | Week 2

• Introduction
• Resources
• Reminder
• Assignment 1
• Assignment 2
• Looking Ahead

☰Menu

Walden University

NRNP 6675: PMHNP Care Across the Lifespan II

• Week 2
• Introduction
• Resources
• Reminder
• Assignment 1
• Assignment 2
• Looking Ahead
• My Progress Tracker

NRNP 6675: PMHNP Care Across the Lifespan II | Week 2

• Introduction
• Resources
• Reminder
• Assignment 1
• Assignment 2
• Looking Ahead

☰Menu

• ×

• NRNP 6675: PMHNP Care Across the Lifespan II

• Back to Course Home

• Course Calendar
• Syllabus
• Course Information
• Resource List
• Support, Guidelines, and Policies

• Module 1
• Week 1
• Week 2
• Module 2
• Week 3
• Week 4
• Week 5
• Week 6
• Week 7
• Module 3
• Week 8
• Week 9
• Week 10
• Week 11

Exit and return to the Blackboard App menu to access other tools, assessments, and content. Pull down, then click the “X” button at the top left corner of your mobile device.

Photo Credit: thanksforbuying / Adobe Stock

Week 2: Coding/Billing and Study Plan

Reimbursement and the appropriate coding to support it are of paramount importance to the business side of the medical field. When a service is provided, a code is used to extract billable information from the medical documentation, which results in insurance reimbursements to the provider. Reimbursement rates and medical coding can be almost as complicated as treating some mental illnesses, and you will need to understand how to accurately code services for documentation, billing, and reimbursement.

This week, you analyze the relationships among documentation, coding, and billing in advanced practice nursing as you practice applying diagnostic criteria and service codes to a case study. You will also evaluate the progress you made on the study plan that you created in NRNP 6665 and develop additional goals to help you prepare for your nurse practitioner national certification exam. 

Learning Objectives

Students will:

• Apply DSM-5-TR diagnosis criteria and ICD-10 codes to patient service documentation
• Analyze the relationships among documentation, coding, and billing in advanced practice nursing
• Evaluate mastery of nurse practitioner knowledge in preparation for the nurse practitioner national certification examination
• Create a study plan for the nurse practitioner national certification examination

Learning Resources

Required Readings (click to expand/reduce)

American Psychiatric Association. (2020). Updates to DSM–5 criteria, text and ICD-10 codes. https://www.psychiatry.org/psychiatrists/practice/dsm/updates-to-dsm-5

American Psychiatric Association. (2013). Insurance implications of DSM-5. https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM_Insurance-Implications-of-DSM-5.pdf

• Clicking on this link will initiate the download of the PDF.

American Psychiatric Association. (2020). Coding and reimbursement.

https://www.psychiatry.org/psychiatrists/practice/practice-management/coding-reimbursement-medicare-and-medicaid/coding-and-reimbursement

American Psychiatric Association. (2013). Numerical listing of DSM-5 diagnoses and codes (ICD-10-CM). In Diagnostic and statistical manual of mental disorders (5th ed.). https://go.openathens.net/redirector/waldenu.edu?url=https://dsm.psychiatryonline.org/doi/10.1176/appi.books.9780890425596.ICD10Num_list

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. (2020). Your billing responsibilities. https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/ProviderServices/Your-Billing-Responsibilities

Stewart, J. G., & DeNisco, S. M. (2019). Role development for the nurse practitioner (2nd ed.). Jones & Bartlett Learning.

• Chapter 15, “Reimbursement for Nurse Practitioner Services”

Walden University Academic Skills Center. (2017). Developing SMART goals. 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”

Document: E/M Patient Case Study

Reminder: Keep Your Library of Advanced Practice Nursing Texts at Your Fingertips

Several textbooks are assigned in multiple courses in your program. That is, you will see reading assignments from the books assigned in the Learning Resources of more than one course. You should, however, keep all prior textbooks, not just the ones explicitly assigned, readily accessible. The expectation is that you will independently consult these prior textbooks to synthesize information needed to complete your final courses. This is your time to “put it all together” to more fully embrace the advanced practice nursing role. Part of the responsibility of advanced practice is developing information literacy skills to know where to locate needed information for your clinical practice. 

Photo Credit: [Peter Polak]/[iStock / Getty Images Plus]/Getty Images

Assignment 1: 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 patient and perform a crosswalk of codes from DSM-5-TR to ICD-10. 

Photo Credit: Getty Images/Tetra images RF

To Prepare

• Review this week’s Learning Resources on coding, billing, reimbursement.
• Review the E/M patient case scenario provided.

The Assignment

• Assign DSM-5-TR 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-TR 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.   

By Day 7 of Week 2

Submit your Assignment. 

Submission and Grading Information

To submit your completed Assignment for review and grading, do the following:

• Please save your Assignment using the naming convention “WK2Assgn1+last name+first initial.(extension)” as the name.
• Click the Week 2 Assignment 1 Rubric to review the Grading Criteria for the Assignment.
• Click the Week 2 Assignment 1 link. You will also be able to “View Rubric” for grading criteria from this area.
• Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK2Assgn1+last name+first initial.(extension)” and click Open.
• If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database.
• Click on the Submit button to complete your submission.

Grading Criteria




To access your rubric:

Week 2 Assignment 1 Rubric

Check Your Assignment Draft for Authenticity




To check your Assignment draft for authenticity:

Submit your Week 2 Assignment 1 draft and review the originality report.

Submit Your Assignment by Day 7 of Week 2




To participate in this Assignment:

Week 2 Assignment 1

Assignment 2: Study Plan

Photo Credit: [Jacob Ammentorp Lund]/[iStock / Getty Images Plus]/Getty Images

Can you imagine an athlete deciding to run a marathon without training for the event? Most ambitious people who have set this goal will follow a specific training plan that will allow them to feel confident and prepared on the big day. Similarly, if you want to feel confident and prepared for your certification exam, you should create and follow a plan that will thoroughly prepare you for success.

In this Assignment, you will review the study plan that you developed in NRNP 6665, and revise your plan as necessary, which will serve as the road map for you to follow to attain your certification.

To Prepare

• Reflect on the study plan you created in NRNP 6665. Did you accomplish your SMART goals? What areas of focus still present opportunities for growth?

The Assignment

• Revise your study plan summarizing your current strengths and opportunities for improvement.
• Develop 3–4 new SMART goals for this quarter and the tasks you need to complete to accomplish each goal. Include a timetable for accomplishing them and a description of how you will measure your progress.
• Describe resources you would use to accomplish your goals and tasks, such as ways to participate in a study group or review course, mnemonics and other mental strategies, and print or online resources you could use to study.

By Day 7 of Week 2

Submit your study plan.

Submission and Grading Information

To submit your completed Assignment for review and grading, do the following:

• Please save your Assignment using the naming convention “WK2Assgn2+last name+first initial.(extension)” as the name.
• Click the Week 2 Assignment 2 Rubric to review the Grading Criteria for the Assignment.
• Click the Week 2 Assignment 2 link. You will also be able to “View Rubric” for grading criteria from this area.
• Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK2Assgn2+last name+first initial.(extension)” and click Open.
• If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database.
• Click on the Submit button to complete your submission.

Grading Criteria




To access your rubric:

Week 2 Assignment 2 Rubric

Check Your Assignment Draft for Authenticity




To check your Assignment draft for authenticity:

Submit your Week 2 Assignment 2 draft and review the originality report.

Submit Your Assignment by Day 7 of Week 2




To participate in this Assignment:

Week 2 Assignment 2

What’s Coming Up in Module 2?

Photo Credit: [BrianAJackson]/[iStock / Getty Images Plus]/Getty Images

In Module 2, you will practice assessing, diagnosing, and formulating treatment plans for various mental health disorders across the lifespan. You will also explore controversies and treatment issues related to certain disorders. Disorders not covered in NRNP 6665 will be covered in this course. You will complete your midterm exam in Week 6. 

Next Module




To go to the next module:

Module 2