Pertinent information generally required in documentation to support DSM-5 and ICD-10 coding includes the patient’s diagnosis, symptoms, clinical assessment findings, treatments provided, medications prescribed (if applicable), current mental status examination, Functional Assessment Rating Scale scores (FARS), and any relevant medical history. It is also important to include a narrative of the patient’s symptoms and treatments. Furthermore, documentation should demonstrate how the diagnosis was established using official diagnostic criteria from DSM-5 or ICD-10.

In this case scenario pertinent information missing includes an initial mental status examination; a detailed assessment of presenting symptoms; FARS scores; details on treatment interventions (e.g., type of therapy administered); and evidence that diagnostic criteria from either DSM-5 or ICD-10 were used to establish the diagnosis.

Explain what pertinent information, generally, is required in documentation to support DSM-5 and 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.

To improve documentation for maximum reimbursement it is important to include all relevant information with clear assessments and descriptions about the patient’s condition in detail including their Wellness/Illness Management model score as well as any other scales applied during evaluation such as PHQ 9 & GAD 7 scores or reports from previous visits which may help explain changes in diagnoses over time if applicable. Additionally documenting “time units” for each intervention with start/stop times for both face-to face sessions as well as telephone services can be beneficial when submitting claims for billing purposes.