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Psychiatric Patient Evaluation Assignment Paper

By Karen Kostick, RHIT, CCS, CCS-P

Attention-Deficit/Hyperactivity Disorder (ADHD) is a chronic neurobehavioral disorder and often associated with serious areas of impairment and comorbidities over a life span. Physician practice coding professionals are at the forefront to ensure quality ICD-10-CM coded data across a life span for ADHD. In ICD-10-CM, ADHD coding over a life span requires clinical coding expertise across multi-physician specialties including but not limited to psychiatry, pediatrics, internal medicine, and family practice. This article summarizes how complete and accurate ADHD ICD-10-CM coding results in complete and quality coded data for the physician office provider setting. Psychiatric Patient Evaluation Assignment Paper

Diagnosing ADHD

ADHD is a clinical diagnosis based on symptomatology and evidence that the symptoms are interfering with social, academic, or occupational functioning. A comprehensive evaluation is required to diagnose ADHD and consists of a thorough diagnostic interview, information obtained from independent sources such as family members or teachers, diagnostic symptom checklists, standardized behavior rating scales for ADHD, and other types of clinical assessment testing as defined by the clinician.

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The American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) provides standardized diagnostic criteria and clinical guidelines for use in the comprehensive evaluation for ADHD. The DSM-5 describes the essential feature of ADHD as a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development.¹ In DSM-5, ADHD is determined based on the patient’s age, the number and severity of symptoms, the duration of symptoms, the presence of symptoms in two or more settings (i.e., home, school, work), and evidence of symptoms interfering with or reducing the quality of life, social, academic, or occupational functioning. Also, clinicians must be able to determine whether the symptoms are caused by other conditions or are influenced by co-existing conditions.

The DSM-5 edition, released in 2013, incorporated ADHD diagnostic criteria updates, which resulted in more age-appropriate and slightly broadened diagnostic criteria that affects how the disorder is diagnosed in older adolescents and adults. Psychiatric Patient Evaluation Assignment Paper

Noteworthy DSM-5 ADHD diagnostic criteria updates in this area include:

ADHD was moved to the neurodevelopmental disorders chapter to better reflect how brain development correlates with ADHD. Thus, with the introduction of DSM-5, ADHD is no longer classified as a childhood disorder but as a chronic lifelong disorder.
Adult symptom examples have been added to the diagnostic criteria to facilitate diagnosing ADHD across the life span rather than just in childhood.
The age of onset was updated from “symptoms that caused impairment were present before age 7 years” to “several inattentive or hyperactive-impulsive symptoms were present prior to age 12”

DSM-5 classifies ADHD in three presentations:

Predominantly Inattentive Presentation
Predominantly Hyperactive-Impulsive Presentation
Predominately Combined Presentation

In addition to the ADHD presentation, DSM-5 further classifies the ADHD severity of the present symptoms as “mild,” “moderate,” or “severe.”

ICD-10-CM ADHD codes are classified in Chapter 5: Mental, Behavioral and Neurodevelopmental disorders. This chapter provides a coding note which states, “Codes within categories F90-F98 may be used regardless of the age of a patient. These disorders generally have onset within the childhood or adolescent years, but may continue throughout life or not be diagnosed until adulthood.” Psychiatric Patient Evaluation Assignment Paper

ICD-10-CM codes for ADHD include:

0, Attention-deficit hyperactivity disorder, predominantly inattentive type
1, Attention-deficit hyperactivity disorder, predominantly hyperactive type
2, Attention-deficit hyperactivity disorder, combined type
8, Attention-deficit hyperactivity disorder, other type
9, Attention-deficit hyperactivity disorder, unspecified type

The ADHD diagnosis is not established at the time of the initial physician office visit. Therefore, it may take two or more visits before the diagnosis is confirmed or ruled out. ICD-10-CM outpatient coding guidelines specify not to assign a diagnosis code when documented as “rule out,” “working diagnosis,” or other similar terms indicating uncertainty. Instead, the outpatient coding guidelines specify to code the condition(s) to the highest degree of certainty for that encounter/visit, which may require using symptoms, signs, or another reason for the visit.

Also, outpatient coding guidelines state that history codes (categories Z80 – Z87) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment. Personal and family history of ADHD has an impact on the clinical assessment of an individual for this disorder; the ICD-10-CM codes to report the history of ADHD in an individual include:

59, Personal history of other mental and behavioral disorders
8, Family history of other mental and behavioral disorders Psychiatric Patient Evaluation Assignment Paper

Table 1

Prevalence of Coexisting Conditions in Children with ADHD
Oppositional Defiant Disorder	40 percent
Conduct Disorder	27 percent
Depression	14 – 15 percent
Anxiety	19 – 30 percent
Tics or Tourette Syndrome*	< 10 percent
Learning disorder (dyslexia, dysgraphia, dyscalculia)	45 percent
Speech problems	12 percent
Sleep problem (insomnia, excessive daytime sleepiness)	25 – 50 percent
*60 to 80 percent of those with Tourette Syndrome have ADHD
Prevalence of Coexisting Conditions in Adults with ADHD
Conduct Disorder	20 – 25 percent
Mood disorder Psychiatric Patient Evaluation Assignment Paper	38 percent
Depression	47 percent
Anxiety	53 percent
Bipolar Disorder	up to 20 percent
Substance Abuse	15 percent
Source: Children and Adults with Attention-Deficit/Hyperactivity Disorder. “Coexisting Conditions.” www.help4adhd.org/Understanding-ADHD/For-Professionals/For-Healthcare-Professionals/The-ADHD-Diagnostic-Process/Coexisting-Conditions.aspx.

Coexisting Conditions with ADHD

According to the National Resource Center on ADHD, more than two-thirds of individuals with ADHD have at least one or more coexisting condition(s). Table 1, above, identifies frequent coexisting conditions in children and adults with ADHD.² Across a life span, some coexisting conditions with ADHD include conduct disorder, depression, and anxiety, which may occur during both childhood and adulthood life stages. Other coexisting conditions with ADHD occur more frequently in childhood such as learning disorders and Tourette Syndrome. Coexisting conditions that occur more often in adulthood stages of ADHD include bipolar disorder and substance abuse disorders.

Due to the high comorbidity associated with ADHD, per outpatient coding guidelines, it is important to code all documented conditions that coexist at the time of the office visit and require or affect patient care, treatment, or management. Psychiatric Patient Evaluation Assignment Paper

Screening and Detecting ADHD

In addition to common co-existing conditions with ADHD, emerging research studies have identified that individuals with ADHD are more likely to experience eating disorders, accidents, physical injuries, and premature death compared to individuals without ADHD. These emerging research topics emphasize the importance of physicians providing consistent screening to individuals with ADHD.

For children diagnosed with ADHD, screening during distinct life stages (young adolescence to teenage to young adult) significantly reduces the risk of developing serious comorbid conditions associated with ADHD. For example, the American Association of Pediatrics (AAP) recommends pediatricians should increase their capacity in providing substance use detection, assessment, and intervention as part of routine wellness exams for older adolescents and teenagers.

This recommendation is particularly important for ADHD individuals who are at a higher risk to misuse alcohol, tobacco, and other illicit substances compared to adolescents without ADHD.³

For undiagnosed adults, physicians are highly encouraged to screen for ADHD in their adult patients during preventive medicine and routine wellness exams. The World Health Organization Adult ADHD Self-Report Scale (ASRS) for DSM-5 is an example of a screening tool for use in the primary care settings.⁴ The scale reflects the DSM-5 adult manifestation of ADHD symptoms, consists of six questions, is easily scored, and has been reported to detect adult ADHD cases in the general population with high sensitivity and specificity. Psychiatric Patient Evaluation Assignment Paper

This type of screening allows primary care physicians who have limited time with each patient to quickly and easily determine whether or not to recommend patients for further ADHD evaluation. The ICD-10-CM Z00.00 – Z00.129 codes for general adult or routine child examinations with and without abnormal findings are used to report ADHD screening and detection during routine health examinations.

Medication Therapy

ADHD includes a multifaceted treatment and the focus is on reducing ADHD symptoms and improving functioning. Effective treatment examples include long-term medication therapy, academic intervention, and cognitive behavioral therapy. Medication (stimulant and non-stimulant) often provides the first line of treatment for many individuals with ADHD, but not all.

The 2017 Merit-based Incentive Payment System (MIPS) includes an important physician ADHD medication quality measure on the percentage of children from six to 12 years of age that were newly dispensed a medication for ADHD who had appropriate follow-up care.

The MIPS quality measure details can be viewed online at https://qpp.cms.gov/mips/quality-measures.

ICD-10-CM code Z79.899, Other long term (current) drug therapy, should be assigned for ADHD individuals who are treated with long-term medication therapy. This status code assignment will assist in differentiating between ADHD individuals who are treated long-term with medication therapy versus ADHD individuals who do not receive long-term medication therapy. Psychiatric Patient Evaluation Assignment Paper

FY2018 ADHD Code Updates

The FY2018 ICD-10-CM code updates that go into effect on October 1, 2017 include updates to ADHD and many coexisting condition codes associated with ADHD. The ICD-10-CM code updates incorporate DSM-5 terminology into the ADHD and associated coexisting condition codes. For example, the inclusion term update for code F90.1, Attention-deficit hyperactivity disorder specifies this ADHD type as ‘hyperactive-impulsive’ which reflects DSM-5 terminology. Also, code F40.1, Social phobias has been updated with the addition of the inclusion term for social anxiety disorder.

Emerging Research Interest and Clinical Initiatives

Over the past several decades, ADHD has only been largely studied in the pediatric and adolescent population. The emergent research interest on adults with ADHD has become of clinical importance as endorsed by the DSM-5 updated ADHD diagnostic criteria specific for adults as well as the recent recommended initiative for physician specialties to integrate the World Health Organization Adult ADHD Self-Report Scale (ASRS) for DSM-5 into wellness exams for undiagnosed adult patients. Psychiatric Patient Evaluation Assignment Paper

The emerging research interest and clinical initiatives have significant potential for an increase in diagnosing and treating ADHD in the physician office setting for the adult population.

More than ever before, when it comes to ADHD coding, physician practice coding professionals need to provide clinical coding expertise to ensure physician practices’ ICD-10-CM coded data completely and accurately captures the clinical assessment, intervention, treatment, and quality long-term care management of the ADHD disorder across the patient’s life span.

Notes

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Washington, DC: American Psychiatric Association Publishing, 2013. p. 51.

Children and Adults with Attention-Deficit/Hyperactivity Disorder. “Coexisting Conditions.”

Harstad, Elizabeth and Sharon Levy. “Attention-Deficit/Hyperactivity Disorder and Substance Abuse.” Pediatrics 134, no. 1 (July 2014).

Ustun, B. et al. “The World Health Organization Adult Attention-Deficit/Hyperactivity Disorder Self-Report Screening Scale for DSM-5.” JAMA Psychiatry 74, no. 5 (May 1, 2017).

References

American Academy of Pediatrics. “AAP Recommends Substance Abuse Screening as Part of Routine Adolescent Care.” October 31, 2011.

American Academy of Pediatrics. “ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents.” Pediatrics 128, no. 5 (November 2011).

American Psychiatric Association. DSM-5 Update: Supplement to Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC: American Psychiatric Association Publishing, September 2016.

Centers for Medicare and Medicaid Services. “2018 ICD-10 CM and GEMs: 2018 Addendum.”

Centers for Medicare and Medicaid Services. “ICD-10-CM Official Guidelines for Coding and Reporting FY 2017.”

National Comorbidity Survey. “Adult ADHD Self-Report Scales (ASRS).”

Karen Kostick ([email protected]) is senior technical business analyst at Nuance Communications, Inc. Psychiatric Patient Evaluation Assignment Paper

Instructions

Use the following case template to complete Week 2 Assignment 1. On page 5, assign DSM-5-TR and Updated 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. Psychiatric Patient Evaluation Assignment Paper

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. Psychiatric Patient Evaluation Assignment Paper

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 Psychiatric Patient Evaluation Assignment Paper

· 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.) Psychiatric Patient Evaluation Assignment Paper	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. Psychiatric Patient Evaluation Assignment Paper

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-TR and Updated ICD-10 coding]

Double click inside this text box to add/edit text. Delete placeholder text when you add your answers.

Treatment Plan

1) 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

2) 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. Psychiatric Patient Evaluation Assignment Paper

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.

3) Patient was educated about therapy and services of the MHC including emergent care. Referral was sent via email to therapy team for PET treatment.

4) 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.

5) 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.

6) RTC in 30 days

7) 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. Psychiatric Patient Evaluation Assignment Paper

Narrative Answers

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[In 1-2 pages, address the following:

· Explain what pertinent information, generally, is required in documentation to support DSM-5-TR and Updated 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.] Psychiatric Patient Evaluation Assignment Paper

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. Psychiatric Patient Evaluation Assignment Paper

Psychiatric Patient Evaluation Assignment Paper