FY 2024: MDC 19 - Mental Disorders

Transcript

1. H I M | C O D I N G & C D I | H E A LT H I T | R E V C Y C L E Empowering Better Health e4health tackles healthcare’s data, quality and revenue challenges empowering your providers to focus on better care.
2. MDC 19 Mental Diseases and Disorders
3. Objectives • Review MDC 19- Mental Diseases and Disorders with a focus on selected diagnoses and procedures • Learner will acquire a basic understanding of the diagnoses and procedures included in MDC-19 • Discuss Query opportunities in MDC-19 • Review coding clinics relevant to the chosen topics in each DRG
4. MDC 19- MS-DRGs (Medical) • DRG 880 ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION • DRG 881 DEPRESSIVE NEUROSES • DRG 882 NEUROSES EXCEPT DEPRESSIVE • DRG 883 DISORDERS OF PERSONALITY AND IMPULSE CONTROL • DRG 884 ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY • DRG 885 PSYCHOSES • DRG 886 BEHAVIORAL AND DEVELOPMENTAL DISORDERS • DRG 887 OTHER MENTAL DISORDER DIAGNOSES
5. MDC 19- MS-DRGs (Surgical) • DRG 876 O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS
6. Mental disorders due to known physiological conditions Criteria, coding guidelines and query opportunities
7. Mental disorders due to known physiological conditions • Categories F01 through F09, are mental disorders that demonstrate an etiology in the cerebral disease, brain injury, or other insult leading to brain dysfunction • These codes can be primary or secondary cerebral dysfunctions • Primary includes disease, injuries, and insults affecting the brain directly • Secondary includes systemic disease and disorders that attack the brain as only one of the multiple organs or body systems involved • Within each categories, there are instructional notes to include “code first” This Photo by Unknown author is licensed under CC BY-SA- NC.
8. Mental disorders due to known physiological conditions – Organic brain syndrome • Coded to F09, Unspecified mental disorder due to known physiological condition • Exception is Post-traumatic organic brain syndrome is coded to F07.81, Post-concessional syndrome, followed by an additional code for an associated post-traumatic headache • A general old term used to describe decreased mental function due to a medical disease other than psychiatric illness • Organic brain syndrome causes agitation, confusion, dementia, or delirium • Common in elderly, but not a part of normal aging process Query opportunity • Review documentation for the underlying condition, which can be coded first • Review to clarify altered mental status to see if it is a dementia or a delirium
9. Mental disorders due to known physiological conditions – Organic Anxiety Disorder • Coded to F06.3, Anxiety disorder due to known physiological condition • A transient organic psychosis with significant anxiety • Considered to be a direct physiological effect of a general medical condition Query opportunity • Review documentation for the general medical condition, which can be coded first • Review to clarify altered mental status to see if it is a dementia or a delirium
10. Mental disorders due to known physiological conditions – Dementia Development of multiple cognitive deficits, such as memory, aphasia, apraxia, and agnosia The following categories are utilized based on the etiology and severity of the dementia •F01, Vascular dementia •F02, Dementia in other diseases classified elsewhere •F03, Unspecified Dementia Severity of dementia is coded based on provider documentation and coded to the highest severity level 5th and 6th characters for categories F01 to F03 specify the presence or absence of behavioral disturbances of: •Agitation, Psychotic disturbances, Mood disturbances, Other behavioral disturbances •The ICD-10-CM Tabular for these codes have inclusion notes for expanded examples of behavioral disturbances For all F01, F02, or F03 codes, if the patients has a tendency to wander, code Z91.83, Wandering in diseases classified elsewhere can be assigned as an additional code •Code first the specific dementia from F01-F03 that specified “with other behavioral disturbances” •Followed by the wandering code
11. Mental disorders due to known physiological conditions – Vascular Dementia • Can be an acute or chronic deterioration due to diffuse or focal cerebral infraction as well as caused by single or multiple infarcts • 2nd most common cause of dementia that a varying degree of symptoms such as cognitive impairment, memory loss, personality changes • Categorized to F01, Vascular dementia • Severity of dementia is coded based on provider documentation and coded to the highest severity level • 5th and 6th characters for categories F01 to F03 specify the presence or absence of behavioral disturbances of: • Agitation, Psychotic disturbances, Mood disturbances, Other behavioral disturbances • The ICD-10-CM Tabular for these codes have inclusion notes for expanded examples of behavioral disturbances
12. Dementia: Stage of Severity, Behavioral and Physical Symptoms Coding Clinic Fourth Quarter 2022 Page 14 Dementia is a progressive disease, now also regularly referred to as major neurocognitive disorder. Dementia is characterized by a significant decline in cognitive function in the areas of memory, problem solving, attention, and language skills. It is generally due to an underlying disorder such as cerebrovascular disease or Alzheimer's disease, although the specific underlying condition cannot always be determined. Progression of dementia moves through three stages of cognitive impairment: mild dementia, moderate dementia, and severe dementia Mild dementia includes patients who are no longer fully independent and require occasional daily assistance with activities Moderate dementia involves an extensive functional impact on everyday life with impairment in basic activities. Patients are no longer independent and require frequent assistance with daily living activities. Severe dementia indicates a complete dependency due to severe functional impact on daily life with impairments in basic activities, including basic self-care
13. Dementia: Stage of Severity, Behavioral and Physical Symptoms - Coding Clinic Fourth Quarter 2022 Page 14 (Cont'd) Additional details have been added to the dementia codes to capture the behavioral and psychological symptoms of dementia (BPSD), such as, but not limited to, psychotic disorder, mood disorders, and anxiety. BPSD can be grouped into three broad categories: behavioral disturbances, psychotic disorders, and mood (affective) disorders. The associated disorders such as agitation, anxiety, and combativeness are the conditions responsible for driving care in patients with dementia. Dementia itself is not directly treatable; what is being treated during an encounter or admission are the BPSDs. The stages of dementia and BPSD can vary from patient to patient. Some symptoms, primarily linked to behavior that may develop at one stage may disappear at a later stage. Other symptoms like memory loss or problems with thinking and talking tend to stay and progressively worsen over time. Therefore, it is essential for clinical data purposes to identify the stages at which these disorders develop and how they present in patients.
14. DEMENTIA: STAGE OF SEVERITY, BEHAVIORAL AND PHYSICAL SYMPTOMS CODING CLINIC FOURTH QUARTER 2022 PAGE 14, continued • Question: A patient with known severe dementia due to late onset of Alzheimer's disease and functional quadriplegia is admitted from a senior living facility due to increased agitation and combativeness over the past three days. What is the appropriate code assignment for severe dementia in a patient with agitation and combativeness? • Answer: Assign codes G30.1, Alzheimer's disease with late onset, and F02.C11, Dementia in other diseases classified elsewhere, severe, with agitation. Code R53.2, Functional quadriplegia, may be assigned for the quadriplegia.
15. Mental disorders due to known physiological conditions – Dementia • Category F02, Dementia in other diseases classified elsewhere, includes dementia due a direct physiological effect of a medical condition, such as Alzheimer's or Parkinson's • Upon assigning codes from category F02: • Code first underlying physiological condition (such as G30.9, Alzheimer's) associated with dementia • Followed by the specific F02 code • If the physiologic cause of the dementia is not specified: • Utilized a code from category F03, Unspecified dementia • For all F01, F02, or F03 codes, if the patients has a tendency to wander, code Z91.83, Wandering in diseases classified elsewhere can be assigned as an additional code • Code first the specific dementia from F01-F03 that specified “with other behavioral disturbances” • Followed by the wandering code
16. Alcohol Abuse in Remission and Alcoholic Dementia Coding Clinic First Quarter 2022 Page 25 • Question: A patient with history of alcohol abuse diagnosed with alcoholic dementia presents to the clinic for a follow-up visit. The provider documented that the alcohol abuse is in remission and the patient's memory is impaired due to alcoholic dementia. ICD-10-CM does not provide a specific code for alcoholic dementia due to alcohol abuse. What are the appropriate code assignments to capture this patient's alcohol abuse in remission with alcoholic dementia? • Answer: Assign codes F10.188, Alcohol abuse with other alcohol-induced disorder, and F02.80, Dementia in other diseases classified elsewhere without behavioral disturbance, for alcoholic dementia. Also assign F10.11, Alcohol abuse, in remission.
17. Mild Neurocognitive Disorder due to Known Physiological Condition Coding Clinic Fourth Quarter 2022 Page 16 Mild neurocognitive disorder, also known as mild cognitive impairment (MCI), can be defined as an impairment in memory or thinking that is beyond what is considered normal age-related changes and yet, not so severe that it is considered dementia. Symptoms are subtle and do not significantly affect a patient's daily life and activities. Patients with MCI typically do not experience other disturbances such as personality changes or functional impairments but are at an increased risk for developing dementia caused by Alzheimer's or other neurological conditions. Typical symptoms include forgetfulness and word-finding difficulties. F06.7, Mild neurocognitive disorder due to known physiological condition, and new codes have been created to identify mild cognitive disorder due to other physiological conditions. F06.70, Mild neurocognitive disorder due to known physiological condition without behavioral disturbance F06.71, Mild neurocognitive disorder due to known physiological condition with behavioral disturbance These codes are assigned to capture MCI in patients who have not yet developed dementia. The fifth-digit classifies the presence or absence of behavioral disturbances. This will allow for tracking of the progression of behavioral symptoms that are a significant indicator of the progression of the underlying disease.
18. Mental disorders due to known physiological conditions – Dementia – Query opportunity • Review record for: • Specificity of underlying cause of dementia vs. the presence of mild neurocognitive disorder, also known as mild cognitive impairment (MCI) • Documentation of agitation or combativeness and potential link to the specified dementia • Documentation if the patient suffers from: • Dementia - affects mainly memory, is typically caused by anatomic changes in the brain, has slower onset, and is generally irreversible, OR • Delirium - affects mainly attention, is typically caused by acute illness or drug toxicity (sometimes life threatening) and is often reversible.
19. Mental disorders due to known physiological conditions – Dementia – Query opportunity, Continued • Review record for associated diagnoses such as: • Osteoporosis • Malnutrition • Cachexia • Depression • Anemia This Photo by Unknown author is licensed under CC BY- SA.
20. Mental Status Alterations Criteria, coding guidelines and query opportunities
21. Altered mental status Broad and frequently utilized term as a symptom of a number of different types of illness An alteration in level of consciousness not associated with delirium or another identified condition is classified to category R40 in chapter 18 of ICD-10-CM Category R40 is further subdivided to indicate whether the alteration is identified as somnolence (R40.0), stupor (R40.1), coma (R40.2-), persistent vegetative state (R40.3), or transient alteration of awareness (R40.4) An altered mental status, or a change in mental status, of unknown etiology is coded to R41.82, Altered mental status, unspecified. If the condition causing the change in mental status is known, do not assign code R41.82; code the condition instead. Query opportunity •Review documentation to clarify the causative nature of altered mental status •Review documentation if the AMS meets clinical indicators of: •Encephalopathy and its specificity •Delirium •Dementia
22. Transient Global Amnesia • Form of amnesia that involves short-term memory which is temporary and reversible • Symptoms includes sudden memory loss and repetitive questioning, which can last for a few hours followed by a near-total resolution of memory loss with no particular treatment required • Etiology is unknown but benign. Suspected causes can be due to epilepsy or stroke, however, review of treatment and documentation needs to justify the suspected cause • Transient global amnesia is not psychotic in nature, and it is not considered to be due to ischemia; rather, it is a distinct cerebrovascular condition with its own code, G45.4 Query opportunity • Review documentation to clarify a susceptive causative nature of the amnesia based on • Review documentation of the transient global amnesia meets clinical indicators and treatment plan of: • Encephalopathy and its specificity • Delirium or dementia • Stroke • Epilepsy This Photo by Unknown author is licensed under CC BY.
23. Schizophrenic Disorders Criteria, coding guidelines and query opportunities
24. Schizophrenia Severe mental illness characterized but not limited to: Odd behavior Disorganized thinking and speech Decreased emotional expression or loss of contact with reality Diminished to total social withdrawal Categorized to F20 with the 4th character indicating the type of schizophrenia
25. Schizophrenia
26. Schizophrenic Disorders – Query opportunity • Review record for associated diagnoses such as: • Dehydration • Electrolyte imbalance • Homelessness • Non-compliance • Alcohol/substance use/abuse/dependence
27. Affective Disorders Criteria, coding guidelines and query opportunities
28. Affective Disorders Most common: Depression & Major Depressive disorder (MDD) Bipolar Disorder Anxiety Symptoms can range from mild to severe mood disturbances
29. Depression & Major Depressive Disorder (MDD) • Depression and MDD fall into categories F32 and F33, respectively • Both categories are subdivided with 4th or 5th characters to provide the severity of the disorder, which must be assigned only with provider documentation • F32/33.0 = Mild • F32/33.1 = Moderate • F32/33.2 = Severe, without psychotic features • F32/33.3 = Severe with psychotic features • F32/33.4 = In remission • F32 uses the 4th character to indicate partial remission • F33 uses the 4th character to indicate remission and 5th character to indicate unspecified remission, partial, or full remission • F32/33.5 = In full remission (only used for F32) • F32/33.8 = Other • F32/33.9 = Unspecified
30. Depression, Not Otherwise Specified Coding Clinic Fourth Quarter 2021 Pages 9-10 • A code has been created to identify depression (unspecified) and the narrative at category F32 was revised from Major depress ive disorder, single episode to "Depressive episode." This retitling brings back the WHO ICD-10 category title, and also brings the title into better alignment with all of what has been included in the category. The new code follows: • F32.A Depression, unspecified • Depression is a common mental health disorder. Approximately 30% of patients report symptoms of depression to their primary care providers; however, fewer than 10% of these patients have major depression. Although depression can begin at almost any age, it typically develops during a person's mid-teens, 20s, or 30s. When untreated, an episode of depression may last from 6 months to two years or more, and episodes tend to recur several times over a lifetime. • The exact etiology of depression is unclear; however, risk factors may include heredity, certain physical disorders, emotionally distressing events, changes in hormone levels, and side effects of certain drugs. • Symptoms of depression vary, and typically develop gradually over days or weeks. Symptoms may include anxiety, feelings of loneliness, irritability, sadness, poor concentration, poor hygiene, and loss of interest in activities that were once enjoyed. Some people have poor appetite while others overeat. Some become withdrawn, have difficulty sleeping or sleep more than usual, and some have thoughts of death and suicide. • Previously in ICD-10-CM, the default for Depression not otherwise specified (NOS) was code F32.9, Major depressive disorder, single episode, unspecified. However, this code did not separately capture the actual occurrence of depression not further specified, and statistically inflated the incidence of major depressive disorder.
31. DEPRESSION, NOT OTHERWISE SPECIFIED CODING CLINIC FOURTH QUARTER 2021 PAGES 9-10, continued • Question: A 25-year-old male patient was seen in his physician's office for a follow up visit. He continues to express feelings of loneliness, sadness, and loss of interest in hobbies that he once enjoyed. The provider diagnosed depression. What is the correct code assignment for depression? • Answer: Assign code F32.A, Depression, unspecified, for depression not further specified.
32. Major Depressive Disorder (MDD) Co-morbid conditions can exacerbate, such as: Malnutrition or cachexia Insomnia Dehydration Can cause self-destructive behavior that can lead to suicide Prolonged periods of emotional, mental, and physical exhaustion Also known as monopolar depression or unipolar affective disorder
33. Depression and Anxiety Coding Clinic First Quarter 2021 Pages 10-11 • Question: When the provider's documentation indicates a patient has both depression and anxiety by using terminology such as depression and anxiety or depression with anxiety, are these diagnoses coded separately? Does the classification assume a linkage between the two conditions? There are no Excludes 1 notes that prohibit coding depression and anxiety together. • What is the appropriate code assignment for a patient with depression and anxiety? • Answer: The classification does not assume a linkage between depression and anxiety; therefore, documentation of the two conditions is not sufficient to link them together. Assign codes F32.9, Major depressive disorder, single episode, unspecified, and F41.9, Anxiety disorder, unspecified, when the documentation has not established a linkage between the depression and the anxiety. • If, however, the provider does indicate a relationship between the two conditions, it would be appropriate to assign code F41.8, Other specified anxiety disorders. This code assignment includes anxiety depression and mixed anxiety and depressive disorder. • Mixed anxiety and depressive disorder, also known as MADD, is a distinct clinical diagnosis. In ICD-10-CM, it is not classified the same as unspecified anxiety and depression. Unless there is a linkage in the documentation to indicate a single disorder, these conditions should be coded separately
34. Behavioral and Neurodevelopmental Disorders Coding Clinic Fourth Quarter 2016 Page 14 • New codes have been created in Chapter 5, Behavioral and Neurodevelopmental Disorders (F01-F99), for a variety of conditions to more closely align with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5®), the criteria used by mental health providers to diagnose mental disorders. A summary of those changes follows: (Distributed to the appropriate areas for teaching purposes): • Premenstrual Dysphoric Disorder • Premenstrual dysphoric disorder (F32.81) is a new disorder in DSM-5® • According to DSM-5®, diagnostic features are "the expression of mood lability, irritability, dysphoria, and anxiety symptoms that occur repeatedly during the premenstrual phase of the cycle and remit around the onset of menses or shortly thereafter" • Code F32.81 has an excludes1 note for "premenstrual tension syndrome (N94.3)" • N94.3, Premenstrual tension syndrome is generally considered less severe than premenstrual dysphoric disorder and does not require psychiatric treatment • In addition, code F32.89 has been created for "other specified depressive episodes"
35. Depression and MDD Query opportunity Review documentation for: Specificity of severity Associated conditions, such as: Malnutrition Suicide ideations Dehydration Non-compliance Epilepsy Homelessness Alcohol/substance use/abuse/dependence
36. Bipolar Disorder • Patients experience periods of manic episodes alternating with depression • Are chronic and recurrent with varying severity degrees • Can lead to suicide attempts during depressive episodes and physical violence during manic episodes • Classified as: • Bipolar I : presence of at least one manic episode and usually depressive episodes • Bipolar II : presence of major depressive episodes with at least one hypomanic (less severe mania) episodes • Unspecified bipolar: clear bipolar features that do not meet specific criteria of either above
37. Bipolar Disorder, continued • ICD-10-CM Tabular classifies bipolar to categories: • F30.- Manic episode (includes bipolar disorder, single manic episode; mixed affective episode) • Further specified to identify severity of current episode and indicate psychotic symptom involvement • F31.- Bipolar disorder (includes manic-depressive illness, manic-depressive psychosis, and manic-depressive reaction) • Further specified to identify severity, with or without hypomania, mania, depression, mixed, or in remission, as well as indicate psychotic symptom involvement • Subcategory F31.7, Bipolar, currently in remission, utilizes 5th character to to identify partial or full remission as well as with or without hypomania, mania, depression, mixed, or unspecified • F34.- Persistent mood [affective] disorders (includes cyclothymic disorder and dysthymic disorder) • F39 Unspecified mood [affective] disorder (includes affective psychosis NOS) • Specificity for each bipolar diagnosis must be documented by the medical provider This Photo by Unknown author is licensed under CC BY-SA.
38. Bipolar Disorder and Recurrent Major Depressive Disorder Coding Clinic First Quarter 2020 Page 23 • Question: A patient was diagnosed with bipolar disorder and major depressive disorder recurrent, mild. Category F31, Bipolar disease, has an "Excludes1" note for "major depressive disorder, recurrent (F33-)," and category F33, Major depressive disorder, recurrent, has an "Excludes1" note for "bipolar disorder (F31-)." What code is assigned when both conditions are documented? • Answer: Assign code F31.9, Bipolar disorder, unspecified. • Bipolar disorder includes both depression and mania, and it is more important to capture the bipolar disorder. Therefore, a code for depression would not be reported separately.
39. Bipolar Disorder – Query opportunity Review documentation for: • Specificity of severity • Associated conditions, such as: • Malnutrition • Suicide ideations • Dehydration • Non-compliance • Epilepsy • Homelessness • Alcohol/substance use/abuse/dependence
40. Behavioral and Neurodevelopmental Disorders Coding Clinic Fourth Quarter 2016 Page 14 • New codes have been created in Chapter 5, Behavioral and Neurodevelopmental Disorders (F01-F99), for a variety of conditions to more closely align with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5®), the criteria used by mental health providers to diagnose mental disorders. A summary of those changes follows (Distributed to the appropriate areas for teaching purposes): • Disruptive Mood Dysregulation Disorder • Disruptive mood dysregulation disorder (F34.81) is a new disorder in DSM-5® characterized by severe and recurrent temper outbursts that are grossly out of proportion in intensity or duration to the situation • The outbursts occur on average 3 or more times each week for one year or more • These symptoms go far beyond temperamental children to those with a severe impairment that requires clinical attention • The central feature of this disorder is chronic, severe, persistent irritability • In addition, a new code has been created for "other specified persistent mood disorders" (F34.89)
41. Nonpsychotic mental disorders Criteria, coding guidelines and query opportunities
42. Nonpsychotic Mental Disorders Classified to categories F40 to F48 Includes: Anxiety disorders (F41 through F42) Stress-related reactions (F43) Dissociative and conversion disorders (F44) Somatoform disorders (F45)
43. Anxiety Disorders • Common psychiatric disorders, which can be undetermined and overlooked as a health problem • Fall into categories of: • F40, Phobic anxiety disorders • Which are persistent and irrational fear of a particular type of object, animal, activity, or situation • F41, Other anxiety disorders • Which includes panic disorders, generalized anxiety, disorders, and other specified anxiety disorders • F42, Obsessive-compulsive disorders • Which is a recurrent, persistent, unwanted, and intrusive thoughts, urges, or obsessions behaviors or mental acts that drive (compulsion) a patient to try to lessen anxiety that the obsessions cause
44. Behavioral and Neurodevelopmental Disorders Coding Clinic Fourth Quarter 2016 Page 14 • New codes have been created in Chapter 5, Behavioral and Neurodevelopmental Disorders (F01-F99), for a variety of conditions to more closely align with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5®), the criteria used by mental health providers to diagnose mental disorders. A summary of those changes follows: (Distributed to the appropriate areas for teaching purposes) • Obsessive Compulsive and Related Disorders • Code F42, Obsessive-compulsive disorder, has been expanded and new codes created for two diagnoses newly recognized under DSM-5®: • Hoarding disorder (F42.3) • Hoarding as a symptom of OCD and characterized by the persistent difficulty of discarding or parting with possessions • Can cause harmful emotional, physical, social, financial, and legal behavior to both patient and family members • Excoriation (skin-picking) disorder (F42.4) • Recurrent skin picking resulting in skin lesions despite attempts to decrease or stop picking • Condition is accompanied by other mental disorders • Mixed obsessional thoughts and acts (F42.2) • Other obsessive-compulsive disorder (F42.8) • Obsessive-compulsive disorder, unspecified (F42.9).
45. Stress-Related reactions • Categorized under F43, Reaction to severe stress and adjustment disorder • Acute stress reaction, subcategory F43.0, incudes acute crisis reaction, combat fatigue, crisis state, and psychic shock • Is a result of a patient experiencing or witnessing a traumatic event that causes extreme, disturbing, or unexpected fear, stress, or pain that involves or threatens serious injury, perceived serious injury, or death to self or someone else • Posttraumatic stress disorder (PTSD), subcategory F43.1, has 5th characters that identify unspecified, acute, or chronic • PTSD is a severe anxiety disorder that developed after a psychological trauma • Symptoms of PTSD include difficulty falling or staying asleep, aner, hypervigilance • Can last more than one month and cause significant social, occupational, and physical ailments • If applicable, category Y36, Operations of war, can be a secondary diagnosis if the PTSD is due to war
46. Stress-Related reactions, continued Adjustment disorder, subcategory F43.2, is a psychological response to a stressor or group of stressors that causes emotional or behavioral symptoms Is different than PTSD as it is associated with a less-intense stressor Utilized the 5th character to identify the nature of the reaction as: 0 = Unspecified 1 = With depressed mood 2 = With anxiety 3 = With mixed anxiety and depressed mood 4 = With disturbance of conduct 5 = With mixed disturbance of emotions and conduct 9 = With other symptoms
47. Complicated Bereavement Coding Clinic First Quarter 2014 Page 25 • Question: Working at a psychiatric hospital, we often come across the diagnosis of "complicated bereavement." What is the correct code for "complicated bereavement" when there is no mention of adjustment reaction/disorder? What code is assigned, if the death was not of a family member? • Answer: Assign code F43.21, Adjustment disorder with depressed mood, for "complicated bereavement." Complicated bereavement/grief is described as a grief reaction. The fact that the death was not of a family member does not affect this code assignment. • Code Z63.4, Disappearance and death of family member, is assigned when the diagnostic statement lists only "Bereavement" and it involves a family member. ** Reference: Coding clinic, First Quarter 2014, page 10 According to research, during the first few months after a loss, several signs and symptoms of normal bereavement are similar to those of complicated bereavement. However, symptoms of normal grief typically diminish after several months, whereas signs and symptoms of a complicated bereavement are more prolonged.
48. Dissociative and Conversion Disorders Criteria, coding guidelines and query opportunities
49. Dissociative Disorders • Dissociative disorders involve disruptions or breakdowns of memory, awareness, identity, and perception and can be coded to specify the following: • F44.0, Dissociative amnesia – memory loss caused by trauma or stress, resulting in the inability to recall important personal information • F44.1, Dissociative fugue – rare form of dissociative amnesia that is diagnosed after the fact where the patient may appear normal, but after the episode ends, the patient finds themselves in a new situation with no memory of how they came to be or what they were doing • F44.2, Dissociative stupor – Stupor that follows a trauma and absence of physical or other psychiatric disorder that may explain the stupor. The patient cannot feel external pain and cannot move, but they are not unconscious or sleeping as well as they are aware of their surroundings around them. • F44.81, Dissociative identity – A patient having two more identities that alternate being in control within the same person. Formerly called multiple personality disorder • Specificity for each dissociative disorder diagnosis must be documented by the medical provider
50. Conversion Disorders • Involves where the patient has neurological symptoms but without neurological disease or the determination of a psychologic mechanism • Also known as functional neurological symptom disorder • Symptoms can vary from weakness/paralysis of varying degree, impaired hearing, vision, sensation, speech, seizures, syncope, and other neurological findings • Can be coded to specify the following: • F44.4, Conversion disorder with motor symptom or deficit • F44.5, Conversion disorder with seizures or convulsions • F44.6, Conversion disorder with sensory symptom or deficit • F44.7, Conversion disorder with mixed symptom presentation • Specificity for each conversion disorder diagnosis must be documented by the medical provider
51. Somatoform Disorders Criteria, coding guidelines and query opportunities
52. Somatoform Disorders • Classified to category F45, Somatoform Disorders • Group of psychiatric disorders with unexplained physical symptoms • 4th character, and sometimes 5th & 6th character specifies the following: • F45.0, Somatization disorder – involving multisystem physical symptoms • F45.1, Undifferentiated somatoform disorder – fewer symptoms than somatization disorder • F45.2 - , Hypochondriasis – fear of having a life-threatening illness or condition • Including body dysmorphia • F45.4 - , Pain disorder related to psychological factors • F45.8, Other somatoform disorders • Including psychogenic pruritis and dysmenorrhea • F45.9, Unspecified somatoform disorder – used when criteria are not clearly met for one of the above • Specificity for each dissociative disorder diagnosis must be documented by the medical provider
53. Somatoform Disorders - Pain Related to Psychological Factors Pain disorders related to psychological factors Assign code F45.41, for pain that is exclusively related to psychological disorders. As indicated by the Excludes 1 note under category G89, a code from category G89 should not be assigned with code F45.41 Code F45.42, Pain disorders with related psychological factors, should be used with a code from category G89, Pain, not elsewhere classified, if there is documentation of a psychological component for a patient with acute or chronic pain
54. Nonpsychotic mental disorders – General Query opportunity Review documentation: • Specificity of acuity of PTSD or adjustment disorders • Specificity physical or behavioral symptoms for dissociative, conversion, or somatoform disorders • Associated conditions, such as: • Suicide ideations • Hoarding • Non-compliance • Homelessness • Alcohol/substance use/abuse/dependence
55. BEHAVIORAL SYNDROMES ASSOCIATED WITH PHYSIOLOGICAL DISTURBANCES AND PHYSICAL FACTORS Criteria, coding guidelines and query opportunities
56. BEHAVIORAL SYNDROMES ASSOCIATED WITH PHYSIOLOGICAL DISTURBANCES AND PHYSICAL FACTORS • Categorized to F50 to F59 • Do not assign any codes from this category if the conditions are due to a mental disorder classified elsewhere or are of organic origin • Includes: • F50.- Eating disorders (such as anorexia nervosa and bulimia nervosa) • F51.- Sleep disorders not due to a substance or known physiological condition • F52.- Sexual dysfunction not due to a substance or known physiological condition • F53.- Mental and behavioral disorders associated with the puerperium, not elsewhere classified • F54 Psychological and behavioral factors associated with disorders or diseases classified elsewhere • F55.- Abuse of non-psychoactive substances • F59 Unspecified behavioral syndromes associated with physiological disturbances and physical factors
57. Anorexia Nervosa • Categorized to F50.0 - Anorexia nervosa • Characterized by relentless pursuit of thinness, morbid fear of obesity, distorted body image, and restriction of intake relative to body requirements, leading to low body weight • 5th character identifies: • F50.00, Anorexia nervosa, unspecified • F50.01, Anorexia nervosa, restricted type – patient restricts food intake but do not engage in binge eating or purging • F50.02, Anorexia nervosa, binge eating/purging type – patient regularly binge eat and/or induce vomiting and/or misuse laxatives, diuretics, or enemas
58. Anorexia Nervosa – Query opportunity • Review documentation for: • Clarification between “anorexia”, which may denote the symptom of loss of appetite • Vs. the diagnosis of “anorexia nervosa,” which is a diagnosis of an eating behavior disorder • Associated diagnoses, such as: • Malnutrition and its severity • Acute kidney injury/dehydration • Liver failure • Endocrine abnormalities, such as thyroid and calcium levels • Osteoporosis • Arrhythmias
59. Medical Treatment/Stabilization of Severe Malnutrition due to Anorexia Nervosa Coding Clinic First Quarter 2022 Page 13 • Question: A 51-year-old patient with severe protein calorie malnutrition due to extreme anorexia nervosa, binge-eating purging type, is admitted to the hospital for stabilization of her acute medical conditions and weight restoration, before being transferred to a residential treatment program specializing in eating disorders. The provider also documented that the patient's end stage renal disease, dehydration and kidney stones are complications caused by the anorexia nervosa. Some coding professionals are questioning whether it is appropriate to sequence anorexia nervosa as the principal diagnosis when the admission is for medical stabilization. What is the appropriate principal diagnosis? • Answer: Assign code E43, Unspecified severe protein-calorie malnutrition, as the principal diagnosis, as this condition is the reason for the admission. Code F50.02, Anorexia nervosa, binge eating/purging type, should be assigned as a secondary diagnosis. Since the admission was for treatment/ stabilization of the patient's acute medical conditions, it would not be appropriate to sequence anorexia nervosa as the principal diagnosis. • The circumstances of inpatient admission always govern the selection of principal diagnosis. The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as "that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care."
60. Bulimia Nervosa • Categorized to F50.2 Bulimia nervosa • Characterized by recurrent episodes of binge eating followed by some inappropriate behavior of purging, fasting, or driven exercise which can occur once a week for three months on the average Query opportunity • Review documentation for electrolyte disturbances • Associated diagnoses, such as: • Esophageal varices or ruptures • Malnutrition • Acute kidney injury/dehydration • Liver failure • Arrhythmias
61. Behavioral and Neurodevelopmental Disorders Coding Clinic Fourth Quarter 2016 Page 14 • New codes have been created in Chapter 5, Behavioral and Neurodevelopmental Disorders (F01-F99), for a variety of conditions to more closely align with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5®), the criteria used by mental health providers to diagnose mental disorders. A summary of those changes follows: (Distributed to the appropriate areas for teaching purposes) • Binge Eating Disorder • Binge eating disorder (F50.81) is a new disorder in DSM-5®, and a unique code in ICD-10-CM will help differentiate this condition from other eating disorders. • Recurring episodes of eating significantly more food in a short period of time than most people would eat under similar circumstances, with episodes marked by feelings of lack of control.“ • Individuals may eat too quickly, even when not hungry. It may be associated with feelings of guilt, embarrassment, or disgust and the individual may binge eat alone to hide the behavior. • This disorder is associated with marked distress and occurs, on average, at least once a week over three months. • Binge eating disorder displays a clinical course that differs from both anorexia nervosa and bulimia nervosa. • In addition, code F50.89 has been created for "other specified eating disorder."
62. Avoidant/Restrictive Food Intake Disorder (ARFID) Coding Clinic Fourth Quarter 2017 Page 9 • Code F50.82, Avoidant/restrictive food intake disorder, was created to identify an eating disorder that results in a persistent failure to meet appropriate nutritional and/or energy needs through an individual's diet. • As a result of not getting the proper nutrition, the individual may experience significant weight loss, or have problems gaining weight if the individual is very young. • Eating problems may be caused by difficulty digesting certain foods, avoiding food with certain textures, smell or colors, portion size, lack of appetite, or fear of repeating a bad experience with certain foods. • Describes individuals with symptoms that do not meet criteria for traditional eating disorders such as anorexia nervosa and bulimia nervosa. • There is no evidence of a disturbance in body perception. ARFID may appear in infancy and childhood, but symptoms may also start or persist into adolescence and adulthood. • Early onset indicates a higher risk of an eating disorder developing in the future. In some cases, there is impaired psychosocial functioning around activities where there is food, due to the reluctance to eat in front of others at school, work, restaurants, family functions, etc. • Nutritional deficiencies can be life threatening and require enteral feeding or oral nutritional supplements. Behavioral modification helps to normalize eating. Early detection is important.
63. Nonpsychotic mental disorders – General Query opportunity • Specificity of acuity of PTSD or adjustment disorders • Specificity physical or behavioral symptoms for dissociative, conversion, or somatoform disorders • Associated conditions, such as: • Suicide ideations • Hoarding • Non-compliance • Homelessness • Alcohol/substance use/abuse/dependence Review documentation for:
64. Non-suicidal Self-harm Coding Clinic Fourth Quarter 2021 Pages 26-27 • A new code has been created to describe non-suicidal self-harm (R45.88). The new code provides a way to differentiate between suicidal and non-suicidal self-harm and allows non-suicidal self-harm to be treated and tracked in clinical databases. • Non-suicidal self-harm is directly and intentionally inflicting damage to one's own body without intention of suicide. Self-harm may include cutting, biting, burning, severe abrading or scratching, pinching, banging or punching objects and oneself, and breaking bones. • Self-harm is not a mental illness, but a behavior that indicates a need for better coping skills. It is a harmful way to cope with emotional pain, anger and frustration. Individuals engaging in self-harm report that they do it, because it feels good or it provides a rush. Several illnesses are associated with self-harm, including borderline personality disorder, depression, eating disorders, anxiety or posttraumatic stress disorder. • Self-harm has less to do with the method used to hurt one's body than the intention to hurt oneself. • Question: A 13-year-old presented to the pediatrician's office after his mother witnessed, on several occasions the patient intentionally biting himself. He denied wanting to end his life and stated that he often feels anxious because of stressful situations at school. The provider diagnosed non-suicidal self-harm. What is the correct code assignment for non-suicidal self- harm? • Answer: Assign code R45.88, Non-suicidal self-harm, for this condition. Assign additional codes for any bite injury.
65. References • 3M Clinical Documentation Improvement System Reference • Transient Global Amnesia: A Case Report - PMC (nih.gov) • Vascular Cognitive Impairment and Dementia - Neurologic Disorders - Merck Manuals Professional Edition • Transient Global Amnesia - Neurologic Disorders - Merck Manuals Professional Edition • Functional Neurologic Disorder | National Institute of Neurological Disorders and Stroke (nih.gov) • Dissociative Identity Disorder - Mental Health Disorders - Merck Manuals Consumer Version • Bipolar Disorders - Psychiatric Disorders - Merck Manuals Professional Edition • Obsessive-Compulsive Disorder (OCD) - Psychiatric Disorders - Merck Manuals Professional Edition • Anorexia Nervosa - Psychiatric Disorders - Merck Manuals Professional Edition • Bulimia Nervosa - Psychiatric Disorders - Merck Manuals Professional Edition • AHA ICD-10-CM and ICD-10-PCS Coding Handbook • Cengage: 3-2-1 CODE IT!
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