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Please respond to the below discussion post about this case:
Case 2: The patient is a 50-year-old married white male who is experiencing significant life stressors following his recent job loss, leading to financial worries and impacting his mental and emotional well-being. With no job offers despite numerous applications, he is having trouble sleeping and expresses feelings of helplessness and hopelessness. Additionally, there has been a noticeable change in his alcohol consumption; he has started drinking during the day, a shift from his previous habit of drinking only after work.
Discussion Post:
The appropriate ICD and E&M billing codes can be determined for the scenario presented based on the clinical details shared in the patient’s history
ICD Codes:
F32.9- Major depressive disorder, single episode, unspecified. The patient’s statement of feeling “helpless and hopeless,” along with trouble sleeping, suggests symptoms of depression. I selected this code because the patient displays symptoms of major depression. However, the specific features or duration of the episode are not detailed enough to fit into more specific categories under major depressive disorders (Centers for Disease Control and Prevention, 2024).
Z56.0 – Unemployment, unspecified. This code reflects the patient’s current employment status, which is relevant as he has been laid off and is facing financial worries (Centers for Disease Control and Prevention, 2024).
F10.99 – Alcohol use uncomplicated. The patient’s increased alcohol consumption since being laid off indicates a possible issue with alcohol use that has emerged under the stress of unemployment and financial insecurity (Centers for Disease Control and Prevention, 2024).
E&M Billing Code:
99214- According to the updated E&M (Evaluation and Management) guidelines provided by the American Medical Association (AMA) (2021), for established patients, the requirement is that the billing decision for levels 99212–99215 is based on the level of medical decision-making or the total time spent on the date of the encounter. For these encounters, only one of the three key components (history, examination, or medical decision-making) is required to determine the visit level. The selection of 99214 is justified by the detailed history the patient provided, including his current employment status, change in alcohol use, and symptoms of depression, including sleep disturbances and feelings of hopelessness. Additionally, the patient’s situation involves the clinician making decisions that consider multiple treatment options, such as counseling for depression, referrals for substance abuse treatment, and possibly initiating pharmacotherapy for depression or sleep disturbances. The presenting problems are of moderate severity, as depression and alcohol abuse can significantly impair functioning and quality of life. I choose the higher level code over a lower level code such as 99213, as the complexity of medical decision-making goes beyond low complexity due to the need to address multiple interrelated issues, including mental health and substance use, both of which could have significant impacts on the patient’s overall health and well-being (AAFP, 2024).
References
AAFP. (2024). Coding for Evaluation and Management Services. Www.aafp.org. https://www.aafp.org/family-physician/practice-and-career/getting-paid/coding/evaluation-management.html
American Medical Association . (2021). CPT ® Category I Evaluation and Management (E/M) Services Guidelines Guidelines Common to All E/M Services Time. https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf
Centers for Disease Control and Prevention. (2024). ICD-10-CM. Cdc.gov. https://icd10cmtool.cdc.gov/?fy=FY2024&query=major%20depression
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