Health Medical Homework Help

Instructions:

It is anticipated that the initial discussion post should be in the range of 250-300 words. Substantive content is imperative for all posts. All discussion prompt elements for the topic must be addressed. Please proofread your response carefully for grammar and spelling. All posts should be supported by a minimum of one scholarly resource, ideally within the last 5 years. Journals and websites must be cited appropriately. Citations and references must adhere to APA format.

Prompt:

Review the SOAP note accessed through the link below.

In paragraph form, construct a discussion that supports the Codes you identified.

In the discussion explore how the ICD-10 Codes that you assigned impact third party payor reimbursement for this visit.

Responses need to address all components of the question, demonstrate critical thinking and analysis and include peer-reviewed journal evidence to support the student’s position.

Please be sure to validate your opinions and ideas with in-text citations and corresponding references in APA format.

EXAMPLE:

ICD-10 codes are used to code for a specific diagnosis and/or procedures that the provider completed to ensure proper reimbursement on submitted billing claims. It also allows for tracking conditions, measuring treatment and outcomes, making medical decisions, helps identify abuse or fraud. Using the correct code to the highest specificity level helps the provider provide an accurate picture of the services provided and ensures maximum payout by third-party payers. Correct coding with evidence to support that code is critical for reimbursement and revenue. If a provider provides incorrect billing codes, it can lead to the claim being denied, delayed, partially paid, or even lead to losing their ability to file claims with that payer (National Center for Health Statistics, 2015).

The ICD-10 codes and DSM5 codes that I would assign to the patient from the above SOAP note and why include the following:

• ICD-10 T14.91XA – Suicide Attempt – Initial Encounter – no DSM-IV as suicide is used to diagnose disorders, it is not listed as a standalone diagnosis – based upon information of how the patient was found – with suicide letter, slumped in her car, nonresponsive, and with two empty sleeping pill bottles in the seat. This is a billable/specific code (2021 ICD-10-CM Diagnosis Code, 2021).
• ICD-10 F31.4 / DSM-IV – 296.53 / Bipolar I disorder with current or most recent episode depressed severe without psychotic features– (with major depressive episode DSM-IV – 296.33 / ICD-10 F33.2, cannot code for F33.2 with coding for F31.4, placed here for knowledge) This is based upon the sister’s information of current and past medical history. Once the patient is awake and alert, further screening would be completed to confirm this is still an accurate diagnosis (2021 ICD-10-CM Diagnosis Code, 2021).
• ICD-10 – F10.20 / DSM-IV – 303.90 – Alcohol dependence, uncomplicated. This diagnosis is from the information the sister gave of past alcohol abuse with several detoxification center visits and increased alcohol intake recently. This diagnosis may change once the patient is assessed after becoming oriented and stable (2021 ICD-10-CM Diagnosis Code, 2021).
• ICD-10 – G43.709 – Chronic migraine without aura, not intractable, without status migrainosus – this may be changed once the patient can give history – based upon billable code based on information from sister. This would be explored further once the patient is awake and alert to confirm this or change diagnosis (2021 ICD-10-CM Diagnosis Code, 2021).
• ICD-10 – I83.93 – Asymptomatic varicose veins of bilateral lower extremities – billable code based upon the information from the physical exam (2021 ICD-10-CM Diagnosis Code, 2021).
• ICD-10 – M27.40 – Unspecified cyst of jaw – due to the cystic lesions on chin found during the physical exam (2021 ICD-10-CM Diagnosis Code, 2021).
• ICD-10-PCS GZ2ZZZZ – Crisis Intervention – Based upon suicidal attempt requiring intervention (2021 ICD-10-CM Diagnosis Code, 2021).
• ICD-10 – Z13.31 – Encounter for screening for depression – based upon information received. This is not fully completed until the patient is awake and alert, current code based on the sister’s information of current and past history (2021 ICD-10-CM Diagnosis Code, 2021).
• ICD-10 R78.89 – blood level of lithium – due to lab work completed to check for currently reported medication use levels and determine the level (2021 ICD-10-CM Diagnosis Code, 2021).

These are possible ICD 10 codes. They may change once the patient is awake and alert and can be assessed and interviewed. Items such as CPT codes for labs etc., would also need to be included.

References

2021 ICD-10-CM Diagnosis Code. (2021). Retrieved May 2021, from ICD10Data.com: https://www.icd10data.com/ICD10CM/Codes.

National Center for Health Statistics. (2015). International Classification of Diseases, (ICD-10-CM/PCS) Transition – Background. Retrieved May 2021, from Centers for Disease Control and Prevention (CDC): https://www.cdc.gov/nchs/icd/icd10cm_pcs_background.htm.