Evaluation and Management E/M NRNP 6675
Evaluation and Management E/M NRNP 6675 – Step-by-Step Guide
The first step before starting to write the Evaluation and Management E/M NRNP 6675, it is essential to understand the requirements of the assignment. The first step is to read the assignment prompt carefully to identify the topic, the length and format requirements. You should go through the rubric provided so that you can understand what is needed to score the maximum points for each part of the assignment.
It is also important to identify the audience of the paper and its purpose so that it can help you determine the tone and style to use throughout. You can then create a timeline to help you complete each stage of the paper, such as conducting research, writing the paper, and revising it to avoid last-minute stress before the deadline. After identifying the formatting style to be applied to the paper, such as APA, you should review its use, such as writing citations and referencing the resources used. You should also review how to format the title page and the headings in the paper.
How to Research and Prepare for Evaluation and Management E/M NRNP 6675
The next step in preparing for your paper is to conduct research and identify the best sources to use to support your arguments. Identify the list of keywords from your topic using different combinations. The first step is to visit the university library and search through its database using the important keywords related to your topic. You can also find books, peer-reviewed articles, and credible sources for your topic from PubMed, JSTOR, ScienceDirect, SpringerLink, and Google Scholar. Ensure that you select the references that have been published in the last words and go through each to check for credibility. Ensure that you obtain the references in the required format, for example, in APA, so that you can save time when creating the final reference list.
You can also group the references according to their themes that align with the outline of the paper. Go through each reference for its content and summarize the key concepts, arguments and findings for each source. You can write down your reflections on how each reference connects to the topic you are researching about. After the above steps, you can develop a strong thesis that is clear, concise and arguable. Next you should create a detailed outline of the paper so that it can help you to create headings and subheadings to be used in the paper. Ensure that you plan what point will go into each paragraph.
How to Write the Introduction for Evaluation and Management E/M NRNP 6675
The introduction of the paper is the most crucial part as it helps to provide the context of your work, and will determine if the reader will be interested to read through to the end. You should start with a hook, which will help capture the reader’s attention. You should contextualize the topic by offering the reader a concise overview of the topic you are writing about so that they may understand its importance. You should state what you aim to achieve with the paper. The last part of the introduction should be your thesis statement, which provides the main argument of the paper.
How to Write the Body for Evaluation and Management E/M NRNP 6675
The body of the paper helps you to present your arguments and evidence to support your claims. You can use headings and subheadings developed in the paper’s outline to guide you on how to organize the body. Start each paragraph with a topic sentence to help the reader know what point you will be discussing in that paragraph. Support your claims using the evidence conducted from the research, ensure that you cite each source properly using in-text citations. You should analyze the evidence presented and explain its significance and how it connects to the thesis statement. You should maintain a logical flow between each paragraph by using transition words and a flow of ideas.
How to Write the In-text Citations for Evaluation and Management E/M NRNP 6675
In-text citations help the reader to give credit to the authors of the references they have used in their works. All ideas that have been borrowed from references, any statistics and direct quotes must be referenced properly. The name and date of publication of the paper should be included when writing an in-text citation. For example, in APA, after stating the information, you can put an in-text citation after the end of the sentence, such as (Smith, 2021). If you are quoting directly from a source, include the page number in the citation, for example (Smith, 2021, p. 15). Remember to also include a corresponding reference list at the end of your paper that provides full details of each source cited in your text. An example paragraph highlighting the use of in-text citations is as below:
The integration of technology in nursing practice has significantly transformed patient care and improved health outcomes. According to Smith (2021), the use of electronic health records (EHRs) has streamlined communication among healthcare providers, allowing for more coordinated and efficient care delivery. Furthermore, Johnson and Brown (2020) highlight that telehealth services have expanded access to care, particularly for patients in rural areas, thereby reducing barriers to treatment.
How to Write the Conclusion for Evaluation and Management E/M NRNP 6675
When writing the conclusion of the paper, start by restarting your thesis, which helps remind the reader what your paper is about. Summarize the key points of the paper, by restating them. Discuss the implications of your findings and your arguments. End with a call to action that leaves a lasting impact on the reader or recommendations.
How to Format the Reference List for Evaluation and Management E/M NRNP 6675
The reference helps provide the reader with the complete details of the sources you cited in the paper. The reference list should start with the title “References” on a new page. It should be aligned center and bolded. The references should be organized in an ascending order alphabetically and each should have a hanging indent. If a source has no author, it should be alphabetized by the title of the work, ignoring any initial articles such as “A,” “An,” or “The.” If you have multiple works by the same author, list them in chronological order, starting with the earliest publication.
Each reference entry should include specific elements depending on the type of source. For books, include the author’s last name, first initial, publication year in parentheses, the title of the book in italics, the edition (if applicable), and the publisher’s name. For journal articles, include the author’s last name, first initial, publication year in parentheses, the title of the article (not italicized), the title of the journal in italics, the volume number in italics, the issue number in parentheses (if applicable), and the page range of the article. For online sources, include the DOI (Digital Object Identifier) or the URL at the end of the reference. An example reference list is as follows:
References
Johnson, L. M., & Brown, R. T. (2020). The role of telehealth in improving patient outcomes. Journal of Nursing Care Quality, 35(2), 123-130. https://doi.org/10.1097/NCQ.0000000000000456
Smith, J. A. (2021). The impact of technology on nursing practice. Health Press.
NRNP 6675 Week 2 Assignment 1: Evaluation and Management (E/M) Instructions
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 patient and perform a crosswalk of codes from DSM-5 to ICD-10. Have a look at NRNP 6675 Week 2 Assignment 2 Study Plan.
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 and ICD-10 codes to services based upon the patient case scenario.
Then, in 1 – 2 pages address the following. You may add your narrative answers to these questions to the bottom of the case scenario document and submit altogether as one document.
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.
Week 2 Assignment 1: Evaluation and Management E/M NRNP 6675 Example
| WAlden University, LLC |
| Student Name
College of Nursing-PMHNP, Walden University NRNP 6675: PMHNP Care Across the Lifespan II Faculty Name Assignment Due Date |
Pathways Mental Health
Psychiatric Patient Evaluation
Instructions |
Use the following case template to complete Week 2 Assignment 1. On page 5, assign DSM-5 and 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.
Today, the client denied symptoms of depression, anergia, anhedonia, amotivation, no anxiety, denied frequent worry, reports feeling restlessness, no reported panic symptoms, and no reported obsessive/compulsive behaviors. The 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, and has a hard time focusing and concentrating, affecting her job. Has low frustration tolerance, sleeping 5–6 hrs/24hrs reports nightmares of a previous rape, isolates, fearful of going 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. |
|||||||||||||||||||||||||||||||||||||||||
Diagnostic Screening Results |
Screening of symptoms in the past two weeks: PHQ 9= 0 with symptoms rated as no difficulty in functioning
Interpretation of Total Score GAD 7= 2 with symptoms rated as no difficulty in functioning MDQ screen negative PCL-5 Screen 32 |
|||||||||||||||||||||||||||||||||||||||||
Past Psychiatric and Substance Use Treatment |
· Entered mental health system when she was age 19 after being 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):
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 a 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 a history of self-mutilation behaviors Global Suicide Risk Assessment: The client is found to be at low risk of suicide or violence. However, the risk of lethality increased under the 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 the 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 a 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 is 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. |
|||||||||||||||||||||||||||||||||||||||||
Clinical Impression |
Client is a 25 yo Russian female who presents with a 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; persistent 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 at low risk for self-harm based on her current clinical presentation and her risk and protective factors. |
|||||||||||||||||||||||||||||||||||||||||
Diagnostic Impression |
[Student to provide DSM-5 and 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 decreased 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 was obtained. Not to drive or operate dangerous machinery if feeling sedated. Not to stop the medication abruptly without discussing it 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 the 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 the 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 the discussion and appears to have the 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. |
|||||||||||||||||||||||||||||||||||||||||
Evaluation and Management
Information Required in Documentation to Support DSM-5 and ICD-10 Coding
The documentation includes the symptoms of the condition the patient is suffering. The DSM-5 criteria have an 11 items checklist where the severity of patient symptoms is measured. The DSM includes descriptions, symptoms, and other diagnostic criteria for mental disorders (American Psychiatric Association, 2020). It generates consistent and trustworthy diagnoses used in mental disorder research and gives a common vocabulary for physicians to talk about their patients.
These documents also allow the physicians to document any behavioral changes. The important aspect is that DSM-V aids doctors in diagnosing behavioral health conditions more precisely (Stewart & DeNisco, 2019). ICD-10, on the other hand, aids billing personnel in accurately coding and billing. Because of these distinctions, an EHR system for a behavioral health provider should have both types of coding.
Missing Information and How It Can Be Helpful to Narrow down Billing and Coding Options
There should be more information about the patient’s strategies to cope with stress and triggers. This information will ensure that if the strategy needs physicians or medication, they are documented for billing (Buppert, 2021). It is also essential to measure whether the patients’ support needs are. Suppose the patient needs more than a 30-day interval between support. It can be accounted for in billing. It will ensure that the patient appointments are appropriately supported. There should also be information on where the failed medication trial occurred and the adherence plan.
Explain How To Improve Documentation To Support Coding And Billing For Maximum Reimbursement
The use of technology will allow physicians to have accurate data collection methods. It is also essential to provide training to the physicians on the key coding compliances and ensure maximization of the reimbursement issues (Pohontsch et al., 2018). There also needs to be a clinical documentation improvement to enhance adequacy and accuracy.
References
American Psychiatric Association. (2020). Updates to DSM–5 criteria, text, and ICD-10 codes. https://www.psychiatry.org/psychiatrists/practice/dsm/updates-to-dsm-5
Buppert, C. (2021). Nurse practitioner\’s business practice and legal guide (7th ed.). Jones & Bartlett Learning.
Pohontsch, N. J., Zimmermann, T., Jonas, C., Lehmann, M., Löwe, B., & Scherer, M. (2018). Coding of medically unexplained symptoms and somatoform disorders by general practitioners–an exploratory focus group study. BMC family practice, 19(1), 1-11.
Stewart, J. G., & DeNisco, S. M. (2019). Role development for the nurse practitioner (2nd ed.). Jones & Bartlett Learning.
