Use your lecture materials to determine what ICD-10 Codes to assign for this patient encounter.
In paragraph form, construct a discussion that supports the Codes you identified.
In the discussion explore how the ICD-10 Codes that you assigned impact third party payor reimbursement for this visit.
Chief Complaint:
Older sister reports – “Our mother died three weeks ago and we lost our father several months ago. I think that my sister was depressed and just wanted to be with them.”
History of Present Illness:
31-year-old female who was brought to the hospital by ambulance. She was found slumped over in her car in front of the funeral home where memorial services for both her father and mother had recently been held. On the seat beside her were two empty bottles of sleeping pills, a Bible opened to Psalm 23, and a note that read: “I am going to be with mom and dad. It is just too sad being here anymore without them. I love you all and you will be in my prayers.” When she was found by the funeral home director her hair was oily and unkempt and she smelled as if she had not bathed in a long time. She was wearing a dirty orange T-shirt and jeans.
PMH:
Depression when she was a junior in HS which led to psychiatric admissions at 15 and 19 years of age. For these admissions she was treated with antidepressants and psychotherapy. Length of stay for both admissions was approximately 5 weeks. At age 19, following a suicide attempt, she met her first husband in the psych ward of the hospital. Diagnosed with bipolar disorder 6 years ago.
Information from Sister:
Older sister reports ‘hard life’. Reports both parents were alcoholics. Parents would go to bars almost every night and leave the 8 children in the care. The children were eventually removed from the home. Some of the children went to the Catholic girls’ home others were placed in “horrible” foster homes where they were subjected to physical and sexual abuse.
Reports numerous siblings, including the patient, have been through several detoxification centers for alcohol abuse.
Patient is in her second marriage with 3 daughters – 2 from the first marriage and 1 from the current marriage.
Reports that after having her third baby the patient went into a ‘terrible depression’. The patient was under the care of a psychiatrist for this depression and was placed on an anti-depressant after about 3 months of being under the psychiatrist’s care. After 3 weeks of being on this anti-depressant the patient is reported as having gotten ‘really weird’; patient was staying up all night pacing around her house and talking to people on the phone, she would go on shopping sprees for 2-3 days at a time and max out all her credit cards. The patient finally crashed and was taken to the hospital by her family and it was during this admission, 6 years ago, that the patient was diagnosed with bipolar disorder. Sister reports the patient has been on Lithium since being diagnosed with bipolar disorder.
Reports their father had been sick for a while so his death was not unexpected. However, their mother went downhill fast and the patient is reported to not cope well with the mother’s illness/death.
Reports the patient hadn’t been eating lately with noted weight loss. Additionally,
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