Medical Coding and Billing
Medical coding is a multibillion-dollar industry that falls under information technology-enabled services. According to Liebovitz and Fahrenbach (2018), medical coding is the translation of medical terms for diagnoses and procedures into code numbers for standardized code sets.
Medical coding’s goals are to (1) prepare a standardized bill for services provided to the patient and (2) determine the amount to be paid to the provider (Liebovitz & Fahrenbach, 2018). As a result, appropriate and accurate medical coding is required to facilitate reimbursement and payment services. The ICD 10 and DSM V codes have been used in this paper in reference to a case scenario described below. A discussion of the relevant information required to support ICD 10 and DSM V coding is also included.
Application of DSM V and ICD 10 Codes in the Patient Case Scenario Described
As described in the previous assignment, the client is a 25-year-old female Caucasian who presents to the emergency department with chief allegations of anxiety and inability to focus for the past year. Furthermore, she has had a known diagnosis of hypertension for the past year, which she manages through lifestyle changes such as the DASH diet, physical activity, and the limitation of risk behaviors such as alcohol consumption.
Her parents are both still alive, and there is no family history of mental illness. Upon assessment, she is diagnosed with Bipolar 1 (manic phase) with a differential diagnosis of a generalized anxiety disorder (GAD), and her axis III diagnosis of hypertension is maintained. She is discharged home on Quetiapine, Lamotrigine, and Lorazepam and asked to return to the clinic for follow-up after a month.
The ICD 10 codes for the diagnoses above are as follows: bipolar disorder, current episode manic without psychotic features F31.1; generalized anxiety disorder F41.1; essential (primary) hypertension I10 (Chakrabarti, 2018).
The DSM V codes for the psychiatric diagnoses are as stated hereafter bipolar 1 disorder, current or most recent manic episode, mild 296.41 (F31.110); generalized anxiety disorder 300.02 (F41.1) (American Psychiatric Association, 2013). During billing, the ICD 10 codes stated above will be used for payment of the services the client received and also for payment of the care provider.
Pertinent Information Required in Documentation to Support DSM V and ICD 10 Coding
Complete DSM V and ICD 10 coding have prerequisites. The prerequisites for ICD 10 coding include complete and legitimate documentation of patient data, including the history and a comprehensive physical examination and the details of the care provider, patient type, place, and payer (Chakrabarti 2018). Furthermore, the diagnosis and procedures must be documented.
Following that, the accurate and complete code is assigned, and the codes must be consistent with the HIPAA codes and must be current. The codes are then checked to see if they comply with the regulations and policies for correct coding established by the federal and state governments and the Joint Commission (Ellis et al., 2020).
To assign DSM V codes, similarly, complete and legitimate documentation involving the patient’s biodata, the method of admission, a corroborative history and physical examination, the mental state exam, and the details of the services and procedures performed, provider and the payer is required.
Pertinent Information Missing from the Case Scenario Described
The previous case described the patient’s biodata and the main complaint, as well as the diagnosis and potential differential diagnoses. Despite their importance in billing, the details of the care provider, the payer for the services provided, the location where the care took place, and the patient type were not provided.
The information which was left is vital for complete coding and billing processes. Furthermore, any procedures performed would have been included for more effective billing. The patient’s diagnosis was stated as bipolar 1, manic phase; it was not stated whether the mania was mild, moderate, or severe; this would be important in narrowing the billing and coding options.
How to Improve Documentation to Support Coding and Billing for Maximum Reimbursement
Complete documentation is required for accurate coding and billing. Care providers must ensure that the biodata, history, physical examination, and details of the care provider and payer for the services provided are thoroughly documented. Computerized documentation is a better solution for eliminating omissions in the documentation of necessary information.
An electronic health record will provide the complete documentation required for billing, which will also correct spelling errors or errors caused by the care provider’s poor penmanship (Bajowala et al., 2020). The implementation of electronic health records has transformed how healthcare documentation and billing of healthcare services are done.
Medical coding is critical in healthcare because it determines payment for services as well as provider reimbursement. If everything is done correctly, the hospital and its employees will thrive. However, if not done correctly, the hospital suffers significant losses. Although traditional paperwork documentation is still used in healthcare, it is gradually being phased out. Electronic health records are used in modern healthcare to help with documentation and, as a result, improve coding and billing for healthcare services.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. Poltekkes-Kaltim.Ac.Id. http://repository.poltekkes-kaltim.ac.id/657/1/Diagnostic%20and%20statistical%20manual%20of%20mental%20disorders%20_%20DSM-5%20(%20PDFDrive.com%20).pdf
Bajowala, S. S., Milosch, J., & Bansal, C. (2020). Telemedicine pays Billing and coding update. Current Allergy and Asthma Reports, 20(10), 60. https://doi.org/10.1007/s11882-020-00956-y
Chakrabarti, S. (2018). Mood disorders in the international classification of Diseases-11: Similarities and differences with the diagnostic and statistical manual of mental Disorders 5 and the international classification of Diseases-10. Indian Journal of Social Psychiatry, 34(5), 17. https://doi.org/10.4103/ijsp.ijsp_19_18
Ellis, R. P., Hsu, H. E., Song, C., Kuo, T.-C., Martins, B., Siracuse, J. J., Liu, Y., & Ash, A. S. (2020). Diagnostic category prevalence in 3 classification systems across the transition to the International Classification of Diseases, Tenth Revision, Clinical Modification. JAMA Network Open, 3(4), e202280. https://doi.org/10.1001/jamanetworkopen.2020.2280
Liebovitz, D. M., & Fahrenbach, J. (2018). COUNTERPOINT: Is ICD-10 diagnosis coding important in the era of big data? No. Chest, 153(5), 1095–1098. https://doi.org/10.1016/j.chest.2018.01.034