The relevant information needed in documentation to support DSM V coding includes diagnostic clinical features, associated symptoms supporting diagnosis, risk factors, diagnostic measures, prognostic factors, and functional consequences (First et al., 2021). In addition, information on gender and culture-associated diagnostic issues, differential diagnoses, and recording procedures is needed in the documentation. Pertinent information needed in ICD-10 coding includes the causes, clinical manifestations, severity of symptoms, and the type of illness or injury (Monestime et al., 2019).

The case scenario lacks important documentation like the severity of clinical symptoms, primary diagnosis, the patient’s comorbidities, and the differential diagnoses with their DSM V and ICD-10 codes. The coding and billing options can be narrowed down by including information such as the clinician’s details and the patient’s demographic information. The clinician’s details include the name, signature, location, and the National Provider Identifier (NPI). Besides, the patient information should include the name, age/date of birth, and insurance information (Seligson et al., 2021). Furthermore, coding and billing can be narrowed by including details about the clinical visit, such as the date and time of the visit, procedure codes, code modifiers, the number of items used, and authorization data.

Healthcare organizations can improve the quality of clinical documentation by leveraging technology and educating healthcare providers in order to improve coding compliance and maximize reimbursement. Healthcare technology can potentially restructure and optimize coding, claims management, and reimbursement. Technology can make coding and clinical documentation easier (Jaqua et al., 2020). For instance, Computer-assisted coding (CAC) solutions extract data from patient records and transfer it to the coder, allowing the coder to focus on creating a story. In addition, providing staff education is crucial in improving documentation among healthcare providers (Seligson et al., 2021). The staff should be trained on using technology in the documentation and why they need to document in a particular way to support coding and billing processes and ensure maximum reimbursement.