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HPI: 42 young female was evaluated for psychiatric evaluation and referred by her primary care provider for worsening depression and panic symptoms. She is currently prescribed escitalopram 5mg po daily for depression, alprazolam 1mg po daily for anxiety. Today, the client reported symptoms of worsening in past month for depression with anergia, anhedonia, motivation, reports anxiety, frequent worry, reports feeling restlessness, palpitations “feels like everything is closing in on me, can’t focus, hard time breathing,” no reported obsessive/compulsive behaviors. Client reported feelings like want to sleep and never wake up. 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. Has low frustration tolerance, sleeping 10-12 hrs/24hrs, 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 week: Severity Measure for Panic Disorder = Total Score 38 PAST PSYCHIATRIC AND SUBSTANCE USE TREATMENT • Entered mental health system when she was age 29 after a family suicide. • Previous Psychiatric Hospitalizations: • Previous Detox/Residential treatments: • Previous psychotropic medication trials: sertraline (became suicidal), trazodone (worsened nightmares), bupropion (became suicidal) • Previous mental health diagnosis per client/medical record: SUBSTANCE USE HISTORY Have you used/abused any of the following (include frequency/amt/last use): Substance Yes/No Frequency/Last Use Tobacco products NO. ETOH Y last drink 2 weeks ago, reports drinks2 times weekly one drink. Cannabis- NO. Cocaine- NO. Prescription stimulants NO. Methamphetamine NO Inhalants -NO. Sedative/sleeping pills -NO. Hallucinogens -NO. Street Opioids- NO. Prescription opioids- NO. Other: specify (spice, K2, bath salts, etc.)-YES reports one-time ecstasy use as a teenager Any history of substance related: • Blackouts: – • Tremors: – • DUI: – • D/T’s: – • Seizures: – Longest sobriety PSYCHOSOCIAL HISTORY Client was raised by single mother. She is married; has 2 children. Employed at local day care as administrative assistant. Education: High School Diploma. Denied current legal issues. SUICIDE / HOMICIDE RISK ASSESSMENT Suicide Inquiry: Denies active suicidal ideations, intentions, or plans. MENTAL STATUS EXAMINATION She is a 42 yo Hispanic female who looks her stated age. She is cooperative with examiner. She is disheveled, dressed appropriately. There is psychomotor restlessness. Her. Her mood is anxious and mildly irritable. She denies any auditory or visual hallucinations. There is no evidence of any delusional thinking. She denies any current suicidal or homicidal ideation. CLINICAL IMPRESSION The client is a 42 yo Hispanic female who presents with a history of treatment for depression and panic symptoms. Moods are anxious and irritable. She has reported symptoms related to her depression and panic. no evident mania/hypomania, no psychosis, 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 can determine right from wrong and can anticipate the potential consequences of behaviors and actions. Please Answer the following questions. Please include every detail questions. Use the information from the case study above. This is a long assignment. Questions Assign DSM-5-TR diagnoses, ICD-10, and reimbursement codes to services based on the patient case scenario. What reimbursement billing code would be use for this session? Provide justification for using this billing code. Explain what pertinent information is required in documentation to support the chosen DSM-5-TR diagnoses, ICD-10 coding, and billing code.
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