Explain what pertinent documentation is missing from the case scenario, and what other information would be helpful to narrow your coding and billing options.

Week 2 | Nursing homework help

Important information is required for DSM-5/ICD-10 coding. It includes demographic data about patients such as their age, gender and race/ethnicity. This information also contains the symptoms that the patient presents with, such as anxiety or pain. It may include any diagnostic tests (such lab work or imaging), and the treatments given by the physician. It is essential to have complete documentation in order for codes to be assigned that conform with health regulations.

It is lacking pertinent information about the case, including any description of symptoms and diagnostic tests performed. In addition to this information it would be helpful to include details on the patient’s mental state including whether they are alert or lethargic during their visit as well as if there was any guidance given by the provider at discharge such as home care instructions for a follow up appointment etc..

To improve documentation for maximum reimbursement accuracy is key when filling out claims: all diagnoses must be coded correctly according to accepted nomenclature standards & not duplicated even within instance events where permissible per contractually between providers & payers–eliminating errors expedite process while ensuring rate payments determined accordingly timely fashion overall! Also efficiency was improved by reducing the time, materials and manual processes involved in entering billing information digitizing forms and transferring electronically so there are fewer errors made particularly frustrating to fix after submission has been submitted either manually or programmatically.

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