Get Answer: Review Clinical Documentation Question Guide
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What This Question Is About
This question relates to review clinical documentation and requires a structured academic response.
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Structure your response with introduction, analysis, and conclusion.
Key Explanation
This topic involves review clinical documentation. A strong answer should include explanation, application, and examples.
Original Question
Review the clinical documentation in the cases provided below. For this assignment you are auditing the coding for the physician’s work in the outpatient setting (surgery, office visit, or ED). Procedures documented but not done by the physician are not a part of this audit. Review the provided ICD-10-CM and CPT code(s). Determine per coding guidelines if the codes listed are correct. Determine per coding guidelines and the provided clinical documentation if there are any missing codes or modifiers (if warranted). Provide your audit information (per below submission format) for all cases of this Case 5 – Lexus Madison 17-year-old female – Outpatient Clinic Visit Community Mental Health Center Reason for Encounter: This is an established patient that have I seen her at the Center for the past 8 months. The patient has not had any self-injurious behavior or behavioral problems this past week except that she has used marijuana, which she endorses. Today we discussed her treatment, and overall, she is happy with the Dialectical Behavior Therapy (DBT) program and her chemical dependency program. She and I discussed future care and the need for her to get away from her current living arrangements. Counseling/Coordination of Care: Today on this visit, we reviewed how her DBT is going and what skills she could use when she has high urges to use marijuana. We also discussed that I would be doing periodic drug screenings as part of upcoming visits her to the clinic/center. Response to/Complications of Current Medications: None. The patient is happy with her medications as they are. Examination: WNL Abnormal General Appearance X Speech X Mood and affect X Judgment and insight X Orientation X Recent and remote memory X Suicidal/homicidal ideation X Fund of knowledge X Assessment of Current Status: The patient appears to be stabilizing; however, she does appear to have a need for ongoing chemical dependency treatment and support, perhaps on an inpatient basis if the outpatient treatment plan fails to control relapses. Diagnosis: Borderline personality disorder; major depression, recurrent; cannabis dependence. Plan: Continue DBT and chemical dependency treatment. The social worker and the patient should begin to work on alternative living arrangements because the patient is exposed to substance abuse in the current living arrangements and has conflicts with others living in the same apartment. No medication changes at this time. No psychotherapy was done on today’s visit. Over 50 percent Counseling/Coordination of Care? ____Yes _x___No History: Problem-focused Examination: Problem-focused Decision Making: Straightforward Signed: Dr. William Rodriguez Codes assigned: F60.3, F33.9, F12.20, 99212 Are these codes correct, do you agree? If not, what codes would you assign?
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