Evaluation and Management (E/M)
Insurance coding and billing is complex, but it boils down to how to accurately apply a code, or CPT (current procedural terminology), to the service that you provided. The payer then reimburses the service at a certain rate. As a provider, you will have to understand what codes to use and what documentation is necessary to support coding.
For this Assignment, you will review evaluation and management (E/M) documentation for a case study patient. You will analyze the documentation to formulate DSM-5-TR diagnoses and ICD-10 coding. You will formulate a billing code for reimbursement of the case study. You will consider legal and ethical considerations for coding and billing. You will analyze and consider the documentation necessary to support accurate billing and coding procedures.
Resources
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
WEEKLY RESOURCES
To Prepare
- Review this week’s Learning Resources on coding, billing, reimbursement.
- Review the E/M patient case scenario provided.
The Assignment
- Assign DSM-5-TR diagnoses, ICD-10, and reimbursement codes to services based on the patient case scenario.
Then, in 2-3 pages, address the following. You will add your narrative answers to these questions to the bottom of the case scenario document and submit them altogether as one document.
- What reimbursement billing code would you use for this session? Provide your justification for using this billing code. Evaluation and management
- Explain what pertinent information is required in documentation to support your chosen DSM-5-TR diagnoses, ICD-10 coding, and billing code.
- Explain what pertinent documentation is missing from the case scenario and what other information would be helpful to narrow your coding and billing options. (There are at least 12 missing pertinent components of documentation).
- Discuss legal and ethical dilemmas related to overbilling, upcoding, and fraudulent practices. Propose 2 strategies for promoting legal and ethical coding and billing practices within your future clinical roles.
- Finally, explain how to improve documentation to support coding and billing for maximum reimbursement.
- Students, evaluation and management.
- For week 2, you will address coding, billing, and study plan.
Read more on nursing homework help on our blog.
NRNP_6675_Week2_Assignment1_Rubric | ||
Criteria | Ratings | Pts |
In the E/M patient case scenario provided: • Assign DSM-5-TR diagnoses and ICD-10 codes, and reimbursement codes to services based on the patient case scenario. Provides justifications | 20 to >17 pts
Excellent 90%–100% DSM-5-TR diagnoses, ICD-10, and reimbursement codes assigned to the scenario are accurate. Response is justified and demonstrates critical thinking. 17 to >15 pts Good 80%–89% DSM-5-TR diagnoses, ICD-10, and reimbursement codes assigned to the scenario are mostly correct, with 1-2 minor errors. Response is justified but does not demonstrate critical thinking. 15 to >13 pts Fair 70%–79% Missing one of the DSM-5-TR diagnoses, ICD-10, or reimbursement codes assigned to the scenario; contains 2-3 significant errors. Justification is vague or inaccurate. Evaluation and management 13 to >0 pts Poor 0%–69% Missing two or more DSM-5-TR diagnoses, and ICD-10, or reimbursement codes assigned to the scenario; contains 4+ errors, or response is missing. Missing Justification. |
/ 20 pts |
In 2-3 pages, address the following on the provided template: • Explain what pertinent information is required in documentation to support your chosen DSM-5-TR diagnoses, ICD-10 coding, and billing code. | 20 to >17 pts
Excellent 90%–100% The response accurately and concisely explains what reimburse pertinent documentation information is required to support DSM-5-TR diagnoses and ICD-10 coding. Evaluation and management. 17 to >15 pts Good 80%–89% The response accurately explains what pertinent documentation information is required to support DSM-5-TR diagnoses and ICD-10 coding. 15 to >13 pts Fair 70%–79% The response somewhat vaguely or inaccurately explains what pertinent documentation information is required to support DSM-5-TR diagnoses and ICD-10 coding. Evaluation and Management 13 to >0 pts Poor 0%–69% The response vaguely or inaccurately explains what pertinent documentation information is required to support DSM-5-TR diagnoses and ICD-10 coding, or the explanation is incomplete or missing. |
/ 20 pts |
• Explain what pertinent documentation is missing from the case scenario, and what other information would be helpful to narrow your coding and billing options. (There are at least 12 missing pertinent components of documentation). | 15 to >13 pts
Excellent 90%–100% The response accurately and concisely identifies the pertinent missing information from the case scenario and clearly identifies what additional information would narrow coding and billing options. Discusses at least 7 or more missing components of documentation. Evaluation and Management 13 to >11 pts Good 80%–89% The response accurately identifies the pertinent missing information from the case scenario and identifies what additional information would narrow coding and billing options. Discusses at least 4-6 missing components of documentation. Read more on nursing school interview on our blog. 11 to >10 pts Fair 70%–79% The response somewhat vaguely or inaccurately identifies the pertinent missing information from the case scenario and identifies what additional information would narrow coding and billing options. Discusses at least 2-3 missing components of documentation. Evaluation and management. 10 to >0 pts Poor 0%–69% The response vaguely or inaccurately identifies the pertinent missing information from the case scenario or partially identifies what additional information would narrow coding and billing options, or this information is incomplete or missing. Discusses 1 or no conversation of missing components of documentation. |
/ 15 pts |
• Discuss legal and ethical dilemmas related to overbilling, upcoding, and fraudulent practices. Propose 2 strategies for promoting legal and ethical coding and billing practices within your future clinical roles. | 15 to >13 pts
Excellent 90%–100% The response accurately and concisely explains legal and ethical dilemmas with 2 strategy proposals for future clinical practice. 13 to >11 pts Good 80%–89% The response accurately explains but is not concise in explanation of legal and ethical dilemmas with 2 strategy proposals for future clinical practice. 11 to >10 pts Fair 70%–79% The response somewhat vaguely or inaccurately explains legal and ethical dilemmas with 1 strategy proposal for future clinical practice. 10 to >0 pts Poor 0%–69% The response does not or vaguely, inaccurately explains either legal or ethical (not both) dilemmas with 1 or missing strategy proposals for future clinical practice. Evaluation and management |
/ 15 pts |
Written Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria. | 5 to >4 pts
Excellent 90%–100% Paragraphs and sentences follow writing standards for flow, continuity, and clarity…. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria. 4 to >3.5 pts Good 80%–89% Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time…. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive. 3.5 to >3 pts Fair 70%–79% Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time…. Purpose, introduction, and conclusion of the assignment are vague or off topic. 3 to >0 pts Poor 0%–69% Paragraphs and sentences follow writing standards for flow, continuity, and clarity <60% of the time…. Purpose statement, introduction, and conclusion were not provided. Evaluation and management. |
/ 5 pts |
• Finally, explain how to improve documentation to support coding and billing for maximum reimbursement. | 15 to >13 pts
Excellent 90%–100% The response accurately and concisely explains how to improve documentation to support coding and billing for maximum reimbursement. 13 to >11 pts Good 80%–89% The response accurately explains how to improve documentation to support coding and billing for maximum reimbursement. 11 to >10 pts Fair 70%–79% The response somewhat vaguely or inaccurately explains how to improve documentation to support coding and billing for maximum reimbursement. 10 to >0 pts Poor 0%–69% The response vaguely or inaccurately explains how to improve documentation to support coding and billing for maximum reimbursement, or response may be incomplete or missing. Evaluation and management |
/ 15 pts |
Written Expression and Formatting – English Writing Standards: Correct grammar, mechanics, and proper punctuation | 5 to >4 pts
Excellent 90%–100% Uses correct grammar, spelling, and punctuation with no errors 4 to >3.5 pts Good 80%–89% Contains 1-2 grammar, spelling, and punctuation errors 3.5 to >3 pts Fair 70%–79% Contains 3-4 grammar, spelling, and punctuation errors 3 to >0 pts Poor 0%–69% Contains five or more grammar, spelling, and punctuation errors that interfere with the reader’s understanding evaluation and management. |
/ 5 pts |
Written Expression and Formatting – The paper follows correct APA format for parenthetical/in-text citations and reference list. | 5 to >4 pts
Excellent 90%–100% Uses correct APA format with no errors 4 to >3.5 pts Good 80%–89% Contains 1-2 APA format errors 3.5 to >3 pts Fair 70%–79% Contains 3-4 APA format errors 3 to >0 pts Poor 0%–69% Contains five or more APA format errors. |