Assignment 1: 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.

Assignment 1: 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.

Assignment 1: 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.

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.

Resources

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Be sure to review the Learning Resources before completing this activity.

Click the weekly resources link to access the resources.

WEEKLY RESOURCES

Learning Resources

Required Readings

American Psychiatric Association. (2024). CPT coding and reimbursement

Links 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. In Diagnostic and statistical manual of mental disorders

Links 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 coverage

Links to an external site.. https://www.cms.gov/files/document/mln1986542-medicare-mental-health-coverage.pdf

Centers for Medicare & Medicaid Services. (2023). Your billing responsibilities

Links 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”

Document: E/M Patient Case Study (Word document)

Download E/M Patient Case Study (Word document)

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 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.

By Day 7 of Week 2

Submit your Assignment.

submission information

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Next, click on Upload File and select Submit Assignment for review.

Rubric

NRNP_6675_Week2_Assignment1_Rubric

NRNP_6675_Week2_Assignment1_Rubric

Criteria Ratings Pts

This criterion is linked to a Learning Outcome In the E/M patient case scenario provided: • Assign DSM-5-TR diagnoses and ICD-10 codes, and reimbursement codes to services based on the patient case scenario. Provides justifications

20 to >17.0 pts

Excellent 90%–100%

DSM-5-TR diagnoses, ICD-10, and reimbursement codes assigned to the scenario are accurate. Response is justified and demonstrates critical thinking.

17 to >15.0 pts

Good 80%–89%

DSM-5-TR diagnoses, ICD-10, and reimbursement codes assigned to the scenario are mostly correct, with 1-2 minor errors. Response is justified but does not demonstrate critical thinking.

15 to >13.0 pts

Fair 70%–79%

Missing one of the DSM-5-TR diagnoses, ICD-10, or reimbursement codes assigned to the scenario; contains 2-3 significant errors. Justification is vague or inaccurate.

13 to >0 pts

Poor 0%–69%

Missing two or more DSM-5-TR diagnoses, and ICD-10, or reimbursement codes assigned to the scenario; contains 4+ errors, or response is missing. Missing Justification.
20 pts

This criterion is linked to a Learning Outcome In 2-3 pages, address the following on the provided template: • Explain what pertinent information is required in documentation to support your chosen DSM-5-TR diagnoses, ICD-10 coding, and billing code.
20 to >17.0 pts

Excellent 90%–100%

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

17 to >15.0 pts

Good 80%–89%

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

15 to >13.0 pts

Fair 70%–79%

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

13 to >0 pts

Poor 0%–69%

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

This criterion is linked to a Learning Outcome • 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).

15 to >13.0 pts

Excellent 90%–100%

The response accurately and concisely identifies the pertinent missing information from the case scenario and clearly identifies what additional information would narrow coding and billing options. Discusses at least 7 or more missing components of documentation.

13 to >11.0 pts

Good 80%–89%

The response accurately identifies the pertinent missing information from the case scenario and identifies what additional information would narrow coding and billing options. Discusses at least 4-6 missing components of documentation.

11 to >10.0 pts

Fair 70%–79%

The response somewhat vaguely or inaccurately identifies the pertinent missing information from the case scenario and identifies what additional information would narrow coding and billing options. Discusses at least 2-3 missing components of documentation.

10 to >0 pts

Poor 0%–69%

The response vaguely or inaccurately identifies the pertinent missing information from the case scenario or partially identifies what additional information would narrow coding and billing options, or this information is incomplete or missing. Discusses 1 or no conversation of missing components of documentation.
15 pts

This criterion is linked to a Learning Outcome • 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.

15 to >13.0 pts

Excellent 90%–100%

The response accurately and concisely explains legal and ethical dilemmas with 2 strategy proposals for future clinical practice.

13 to >11.0 pts

Good 80%–89%

The response accurately explains but is not concise in explanation of legal and ethical dilemmas with 2 strategy proposals for future clinical practice.

11 to >10.0 pts

Fair 70%–79%

The response somewhat vaguely or inaccurately explains legal and ethical dilemmas with 1 strategy proposal for future clinical practice.

10 to >0 pts

Poor 0%–69%

The response does not or vaguely, inaccurately explains either legal or ethical (not both) dilemmas with 1 or missing strategy proposals for future clinical practice.
15 pts

This criterion is linked to a Learning Outcome 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.

5 to >4.0 pts

Excellent 90%–100%

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.

4 to >3.5 pts

Good 80%–89%

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.

3.5 to >3.0 pts

Fair 70%–79%

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.

3 to >0 pts

Poor 0%–69%

Paragraphs and sentences follow writing standards for flow, continuity, and clarity <60% of the time…. Purpose statement, introduction, and conclusion were not provided.
5 pts

This criterion is linked to a Learning Outcome • Finally, explain how to improve documentation to support coding and billing for maximum reimbursement.
15 to >13.0 pts

Excellent 90%–100%

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

13 to >11.0 pts

Good 80%–89%

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

11 to >10.0 pts

Fair 70%–79%

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

10 to >0 pts

Poor 0%–69%

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.
15 pts

This criterion is linked to a Learning Outcome Written Expression and Formatting – English Writing Standards: Correct grammar, mechanics, and proper punctuation

5 to >4.0 pts

Excellent 90%–100%

Uses correct grammar, spelling, and punctuation with no errors

4 to >3.5 pts

Good 80%–89%

Contains 1-2 grammar, spelling, and punctuation errors

3.5 to >3.0 pts

Fair 70%–79%

Contains 3-4 grammar, spelling, and punctuation errors

3 to >0 pts

Poor 0%–69%

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

This criterion is linked to a Learning Outcome Written Expression and Formatting – The paper follows correct APA format for parenthetical/in-text citations and reference list.

5 to >4.0 pts

Excellent 90%–100%

Uses correct APA format with no errors

4 to >3.5 pts

Good 80%–89%

Contains 1-2 APA format errors

3.5 to >3.0 pts

Fair 70%–79%

Contains 3-4 APA format errors

3 to >0 pts

Poor 0%–69%

Contains five or more APA format errors

5 pts

Total Points: 100