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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.
Question 1: Explain what pertinent information, generally, is required in documentation to support DSM-5 and ICD-10 coding.
Question 2: Explain what pertinent documentation is missing from the case scenario, and what other information would be helpful to narrow your coding and billing options.
Question 3: Finally, explain how to improve documentation to support coding and billing for maximum reimbursement.
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