Case Study
Patient Demographic: Client Age: 41 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Divorced Counseling Setting: Behavioral Health Type of Counseling: Outpatient Presenting Problem: Fear and Panic Diagnosis: Agoraphobia 300.22 (F40.00)
Mental Status Exam: Mental Status Exam: The client appears her stated age, and she is dressed in casual attire. Her affect and mood are anxious. She is tearful and seems extremely distressed when recounting her panic attacks. The client denies suicidal or homicidal ideations but does endorse feeling hopeless about her condition. She is unsure if she will benefit from counseling and expresses mixed feelings about seeking help. The client denies audio and visual hallucinations. Fam
Presenting Problem: You work in a behavioral health outpatient center. Your client is a 41-year-old Caucasian female presenting with symptoms of fear and panic. The client has a history of anxiety and depression but explains that her anxiety has worsened within the last year and that she has begun to experience panic attacks. She states that she has an “overwhelming fear” of elevators and stairwells. When exposed to these situations, she has trouble breathing, begins to feel dizzy, and hyperventilates. The client remembers having her first panic attack while staying at a hotel one weekend. She was taking the stairs and suddenly felt intense fear and panic. On the same trip, she had a similar experience when taking the elevator. The client quit her last job due to travel requirements, and she is currently unemployed. She stays away from stairwells and elevators as much as she possibly can. When unable to do so, she asks her son to accompany her.
Other Contexts:    ily and Work History: The client was married for 15 years before she divorced. She and her ex-husband share custody of their 16-year-old son. The client is an only child and reports that her parents were strict and overbearing when she was growing up. She works as a travel photographer and, until recently, worked for a large national publication. She enjoyed her job but cannot envision a time when she would feel comfortable staying in hotels again. This fear has prevented her from exploring other travel accommodations while on assignment. She states, “There are too many unknowns with travel, and I just don’t think I can do it any longer.”  The client’s insurance company is requesting a level-of-care assessment

Question: The client’s insurance company is requesting a level-of-care assessment. In behavioral health settings, which of the following would best help with this determination?
(A): Treatment summary
(B): Diagnosis
(C): Medical necessity
(D): Payor source

Correct Answer: Medical necessity
Explanation: Insurance providers require clinicians to establish medical necessity when determining a client’s appropriate level of care. Services must be medically necessary to receive provider reimbursement, including approval for the frequency, length, and duration of clinical services. Medical necessity determines preapproval and ongoing approval for authorized services. Medical necessity, service utilization, and functional impairment are considered when assigning a client’s level of care. The level of care is used when determining the least restrictive setting for a client’s treatment, with lower levels of care assigned to those receiving outpatient services and a higher level of care required for more restrictive settings (eg, hospitalization to residential treatment). Diagnosis is a level-of-care consideration, but the diagnosis alone does not reflect functional impairment and the client’s level of distress. In general, treatment summaries are insufficient for determining the level of care. A payor source refers to an individual or entity responsible for charges generated from treatment services. Payor sources request level of care assessments; they do not provide clinical assessment. Therefore, the correct answer is (A)
Competency: professional practice and ethics