The ICD-10 coding system is used to classify diseases and aid in billing and payment. According to Leon-Chisen (2018), it stands for the tenth revision of the International Classification of Diseases, Clinical Modification.

The ICD-10 coding system is used to classify diseases and aid in billing and payment. According to Leon-Chisen (2018), it stands for the tenth revision of the International Classification of Diseases, Clinical Modification.

The information needed in records to complement DSM-5 and ICD-10 classification usually defines what was done to the client and whether the interventions were provided as an outpatient or inpatient.

It’s worth noting, though, that the DSM-5 helps clinicians diagnose more exactly, whereas the ICD-10 helps them classify and bill for payment much more correctly.

This relevant information is that there must be a match in the DSM-5 and ICD-10 codes, it must be indicated whether the client is an inpatient or an outpatient, the procedure or intervention done must be stated exactly and unambiguously including the amount of time it took to do it, there has to be a maximum of 7 alphanumeric characters in the ICD-10 code, and there must be a provision for clinician query process to find out answers to unclear parts of the billing and coding.

The Missing Information According to the resented Case

The following information is missing from the documentation of the case scenario presented:

1. The age at which the ADHD symptoms first appeared. This is because treatment plans for childhood-onset and adult-onset ADHD may differ (Sadock et al., 2015).
2. The duration of the patient’s treatment with fluoxetine and atomoxetine. This, too, may have an impact on the treatment approach, as additional medications may be considered if the therapeutic effect is delayed or non-existent.

Given the preceding observation, further information about the length of time the patient will be on therapy in weeks as well as the duration of each session might be valuable in restricting the coding and billing possibilities.

It would also be beneficial to know if the practitioner performed any more testing to get at the diagnosis.

Improving Documentation for Better Coding and Billing

The quest for higher income for both the practitioner and the organization is centered on proper coding and billing. The following are some of the tactics the business can take to improve billing and coding so that reimbursement claims generate more revenue:

1. Having a designated person whose duty it is to countercheck claims and follow up on any claims that have been denied and need to be resubmitted. This is due to the fact that, as humans, we will occasionally fail to properly document something. When filling out the details in the electronic health record (EHR) system, certain information may have been overlooked.
2. Keeping up with changes in billing and coding protocols that occur from time to time. This guarantees that the organization’s billing and coding methods are up to date.
3. Ensuring that any deadlines established by stakeholders, such as payers, are reached on time.
4. Appointment of a coder to assist physicians with coding so that crucial information required for seamless and better reimbursement is not overlooked. Clinicians, such as physicians, frequently overlook vital information because they believe it is unimportant.
5. Ascertaining that each patient’s primary and secondary payers are identified.
6. Verifying benefits before administering any treatment to avoid administering treatment that is not covered, causing the claim to be refused.