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Altered Mental Health Case Study

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Case Summary

The patient, a 23-year-old male (date of birth September 30, 1994), presented to the facility’s Emergency Department on February 27, 2018, with a history of schizophrenia, seizure disorder, polysubstance abuse (ETOH, marijuana, heroin and BZDs), opiate intoxication, depression and suicidality. The patient was admitted to the Medical Center on February 27, 2018.

The following diagnoses were submitted: Admitting Diagnosis of altered mental status;
Principal Diagnosis of seizure disorder; Secondary Diagnoses: enterocolitis due to Clostridium difficile; suicidal ideation; sedative hypnotic or anxiolytic dependence with withdrawal; opioid dependence with withdrawal; other psychoactive substance use unspecified with mood disorder; …show more content…
Upon detailed review of the medical record, inclusive of the Itemized Bill (listed in chronological order, each specific service and supply/drug billed are supported by the entries and reports as medically necessary and identified as provided in the most appropriate setting: The Room and Board -Isolation and Medical-Surgical Bed Services for 20 days, based on the patient’s diagnoses and treatment requirements. The services are supported as being actually furnished as ordered by the physician(s). There is no evidence of services being duplicately billed.

The medical record evidences no period, during the admission at issue, when the patient was in an alternative level of care. There are no undocumented charges.

Review of the medical documentation confirms that the charges are substantiated by the medical record and adhere to the ICD 10 CM Official Guidelines for Coding and Reporting, Section II. I Admission from Observation Unit and Section III. Reporting Additional Diagnosis; and are medical necessary and appropriate, delivered in the most appropriate setting, ordered and actually

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