ICD-9-CM coding for ADHD

Transcription

1 ICD-9-CM coding for ADHD A number of codes are offered here, reflecting the myriad potentially associated and/or comorbid conditions NEUROTIC DISORDERS, PERSONALITY DISORDERS, AND OTHER NONPSYCHOTIC MENTAL DISORDERS ( ) 314 Hyperkinetic syndrome of childhood Excludes: hyperkinesis as symptom of underlying disorder - code the underlying disorder Attention deficit disorder Adult Child Without mention of hyperactivity Predominantly inattentive type With hyperactivity Combined type Overactivity NOS Predominantly hyperactive/impulsive type Simple disturbance of attention with overactivity Hyperkinesis with developmental delay Developmental disorder of hyperkinesis Use additional code to identify any associated neurological disorder Hyperkinetic conduct disorder Hyperkinetic conduct disorder without developmental delay Excludes: hyperkinesis with significant delays in specific skills (314.1) Other specified manifestations of hyperkinetic syndrome Unspecified hyperkinetic syndrome Hyperkinetic reaction of childhood or adolescence NOS Hyperkinetic syndrome NOS OTHER PSYCHOSES ( ) Use additional code to identify any associated physical disease, injury, or condition affecting the brain with psychoses classifiable to Pervasive developmental disorders Excludes: adult type psychoses occurring in childhood, as: affective disorders ( ) manic-depressive disorders ( ) schizophrenia ( ) The following fifth-digit subclassification is for use with category 299: 0 current or active state 1 residual state Autistic disorder [0-1] Childhood autism Infantile psychosis Kanner's syndrome Excludes: disintegrative psychosis (299.1) Heller's syndrome (299.1) schizophrenic syndrome of childhood (299.9)

2 299.8 Other specified pervasive developmental disorders [0-1] Asperger's disorder Atypical childhood psychosis Borderline psychosis of childhood Excludes: simple stereotypes without psychotic disturbance (307.3) NEUROTIC DISORDERS, PERSONALITY DISORDERS, AND OTHER NONPSYCHOTIC MENTAL DISORDERS ( ) 300 Anxiety, dissociative and somatoform disorders Anxiety states Excludes: anxiety in: acute stress reaction (308.0) transient adjustment reaction (309.24) neurasthenia (300.5) psychophysiological disorders ( ) separation anxiety (309.21) Anxiety state, unspecified Anxiety: neurosis reaction state (neurotic) Atypical anxiety disorder Panic disorder without agoraphobia Panic: attack state Excludes: panic disorder with agoraphobia (300.21) Generalized anxiety disorder Other Phobic disorders Excludes: anxiety state not associated with a specific situation or object ( ) obsessional phobias (300.3) Phobia, unspecified Anxiety-hysteria NOS Phobia NOS Social phobia Fear of: eating in public public speaking washing in public Other isolated or specific phobias Acrophobia Animal phobias Claustrophobia Fear of crowds Obsessive-compulsive disorders Anancastic neurosis Compulsive neurosis Obsessional phobia [any] Excludes: obsessive-compulsive symptoms occurring in: endogenous depression ( ) organic states (e.g., encephalitis) schizophrenia ( )

3 300.4 Dysthymic disorder Anxiety depression Depression with anxiety Depressive reaction Neurotic depressive state Reactive depression Excludes: adjustment reaction with depressive symptoms ( ) depression NOS (311) manic-depressive psychosis, depressed type ( ) reactive depressive psychosis (298.0) 305 Nondependent abuse of drugs Note: Includes cases where a person, for whom no other diagnosis is possible, has come under medical care because of the maladaptive effect of a drug on which he is not dependent and that he has taken on his own initiative to the detriment of his health or social functioning. Excludes: alcohol dependence syndrome ( ) drug dependence ( ) drug withdrawal syndrome (292.0) poisoning by drugs or medicinal substances ( ) The following fifth-digit subclassification is for use with codes 305.0, unspecified 1 continuous 2 episodic 3 in remission Alcohol abuse Drunkenness NOS Excessive drinking of alcohol NOS "Hangover" (alcohol) Inebriety NOS Excludes: acute alcohol intoxication in alcoholism (303.0) alcoholic psychoses ( ) Tobacco use disorder Tobacco dependence Excludes: history of tobacco use (V15.82) smoking complicating pregnancy (649.0) tobacco use disorder complicating pregnancy (649.0) Cannabis abuse Hallucinogen abuse Acute intoxication from hallucinogens ["bad trips"] LSD reaction Sedative, hypnotic or anxiolytic abuse Opioid abuse Cocaine abuse Amphetamine or related acting sympathomimetic abuse Antidepressant type abuse Other, mixed, or unspecified drug abuse Caffeine intoxication

4 Inhalant abuse "Laxative habit" Misuse of drugs NOS Nonprescribed use of drugs or patent medicinals Phencyclidine abuse 307 Special symptoms or syndromes, not elsewhere classified Note: This category is intended for use if the psychopathology is manifested by a single specific symptom or group of symptoms which is not part of an organic illness or other mental disorder classifiable elsewhere. Excludes: those due to mental disorders classified elsewhere those of organic origin Tics Excludes: nail-biting or thumb-sucking (307.9) stereotypes occurring in isolation (307.3) tics of organic origin (333.3) Tic disorder, unspecified Tic disorder NOS Transient tic disorder Chronic motor or vocal tic disorder Tourette's disorder Motor-verbal tic disorder Stereotypic movement disorder Body-rocking Head banging Spasmus nutans Stereotypes NOS Excludes: tics ( ) of organic origin (333.3) Other and unspecified special symptoms or syndromes, not elsewhere classified Communication disorder NOS Hair plucking Lalling Lisping Masturbation Nail-biting Thumb-sucking 309 Adjustment reaction Includes: adjustment disorders reaction (adjustment) to chronic stress Excludes: acute reaction to major stress ( ) neurotic disorders ( ) Adjustment disorder with depressed mood Grief reaction Excludes: affective psychoses ( ) neurotic depression (300.4) prolonged depressive reaction (309.1) psychogenic depressive psychosis (298.0) Prolonged depressive reaction Excludes: affective psychoses ( ) brief depressive reaction (309.0) neurotic depression (300.4) psychogenic depressive psychosis (298.0)

5 309.2 With predominant disturbance of other emotions Separation anxiety disorder Emancipation disorder of adolescence and early adult life Specific academic or work inhibition Adjustment disorder with anxiety Adjustment disorder with mixed anxiety and depressed mood Adjustment reaction with anxiety and depression Other Culture shock Adjustment disorder with disturbance of conduct Conduct disturbance as adjustment reaction Destructiveness as adjustment reaction Excludes: destructiveness in child (312.9) disturbance of conduct NOS (312.9) dyssocial behavior without manifest psychiatric disorder (V71.01-V71.02) personality disorder with predominantly sociopathic or asocial manifestations (301.7) Adjustment disorder with mixed disturbance of emotions and conduct Other specified adjustment reactions Posttraumatic stress disorder Chronic posttraumatic stress disorder Concentration camp syndrome Posttraumatic stress disorder NOS Post-Traumatic Stress Disorder (PTSD) Excludes: acute stress disorder (308.3) posttraumatic brain syndrome: nonpsychotic (310.2) psychotic ( ) Adjustment reaction with physical symptoms Adjustment reaction with withdrawal Elective mutism as adjustment reaction Hospitalism (in children) NOS Other Unspecified adjustment reaction Adaptation reaction NOS Adjustment reaction NOS 312 Disturbance of conduct, not elsewhere classified Excludes: adjustment reaction with disturbance of conduct (309.3) drug dependence ( ) dyssocial behavior without manifest psychiatric disorder (V71.01-V71.02) personality disorder with predominantly sociopathic or asocial manifestations (301.7) sexual deviations ( ) The following fifth-digit subclassification is for use with categories : 0 unspecified 1 mild 2 moderate 3 severe Undersocialized conduct disorder, aggressive type Aggressive outburst Anger reaction Unsocialized aggressive disorder

6 312.1 Undersocialized conduct disorder, unaggressive type Childhood truancy, unsocialized Solitary stealing Tantrums Socialized conduct disorder Childhood truancy, socialized Group delinquency Excludes: gang activity without manifest psychiatric disorder (V71.01) Disorders of impulse control, not elsewhere classified Impulse control disorder, unspecified Pathological gambling Kleptomania Pyromania Intermittent explosive disorder Isolated explosive disorder Other Trichotillomania Mixed disturbance of conduct and emotions Neurotic delinquency Excludes: compulsive conduct disorder (312.3) Other specified disturbances of conduct, not elsewhere classified Conduct disorder, childhood onset type Conduct disorder, adolescent onset type Other conduct disorder Conduct disorder of unspecified onset Unspecified disturbance of conduct Delinquency (juvenile) Disruptive behavior disorder NOS 313 Disturbance of emotions specific to childhood and adolescence Excludes: adjustment reaction ( ) emotional disorder of neurotic type ( ) masturbation, nail-biting, thumb-sucking, and other isolated symptoms ( ) Overanxious disorder Anxiety and fearfulness of childhood and adolescence Overanxious disorder of childhood and adolescence Excludes: abnormal separation anxiety (309.21) anxiety states ( ) hospitalism in children (309.83) phobic state ( ) Misery and unhappiness disorder Excludes: depressive neurosis (300.4) Sensitivity, shyness, and social withdrawal disorder Excludes: infantile autism (299.0) schizoid personality ( ) schizophrenia ( ) Shyness disorder of childhood Sensitivity reaction of childhood or adolescence

7 Introverted disorder of childhood Social withdrawal of childhood or adolescence Withdrawal reaction of childhood or adolescence Selective mutism Excludes: elective mutism as adjustment reaction (309.83) Relationship problems Sibling jealousy Excludes: relationship problems associated with aggression, destruction, or other forms of conduct disturbance ( ) Other or mixed emotional disturbances of childhood or adolescence Oppositional defiant disorder Identity disorder Identity problem Academic underachievement disorder Other Reactive attachment disorder of infancy or early childhood Unspecified emotional disturbance of childhood or adolescence Mental disorder of infancy, childhood or adolescence NOS 314 Hyperkinetic syndrome of childhood See top of document 315 Specific delays in development Excludes: that due to a neurological disorder ( ) Specific reading disorder Reading disorder, unspecified Alexia Developmental dyslexia Other Specific spelling difficulty Mathematics disorder Dyscalculia Other specific learning difficulties Disorder of written expression Excludes: specific arithmetical disorder (315.1) specific reading disorder ( ) Developmental speech or language disorder Expressive language disorder Developmental aphasia Word deafness Excludes: acquired aphasia (784.3) elective mutism (309.83, 313.0, ) Mixed receptive-expressive language disorder Central auditory processing disorder Excludes: acquired auditory processing disorder (388.45) Speech and language developmental delay due to hearing loss Other

8 Developmental articulation disorder Dyslalia Phonological disorder Excludes: lisping and lalling (307.9) stammering and stuttering (307.0) Developmental coordination disorder Clumsiness syndrome Dyspraxia syndrome Specific motor development disorder Mixed development disorder Other specified delays in development Unspecified delay in development Developmental disorder NOS Learning disorder NOS MENTAL RETARDATION ( ) Use additional code(s) to identify any associated psychiatric or physical condition(s) 317 Mild mental retardation High-grade defect IQ Mild mental subnormality 318 Other specified mental retardation Moderate mental retardation IQ Moderate mental subnormality Severe mental retardation IQ Severe mental subnormality Profound mental retardation IQ under 20 Profound mental subnormality 319 Unspecified mental retardation Mental deficiency NOS Mental subnormality NOS 16. SYMPTOMS, SIGNS, AND ILL-DEFINED CONDITIONS ( ) 781 Symptoms involving nervous and musculoskeletal systems Excludes: depression NOS (311) disorders specifically relating to: back ( ) hearing ( ) joint ( ) limb ( ) neck ( ) vision ( ) pain in limb (729.5) Abnormal involuntary movements Abnormal head movements Fasciculation Spasms NOS Tremor NOS

9 Excludes: abnormal reflex (796.1) chorea NOS (333.5) infantile spasms ( ) spastic paralysis (342.1, ) specified movement disorders classifiable to 333 ( ) that of nonorganic origin ( ) Disturbances of sensation of smell and taste Anosmia Parageusia Parosmia Abnormality of gait Gait: ataxic paralytic spastic staggering Excludes: ataxia: NOS (781.3) difficulty in walking (719.7) locomotor (progressive) (094.0) Lack of coordination Ataxia NOS Muscular incoordination Excludes: ataxic gait (781.2) cerebellar ataxia ( ) difficulty in walking (719.7) vertigo NOS (780.4) OTHER AND UNSPECIFIED EFFECTS OF EXTERNAL CAUSES ( ) 995 Certain adverse effects not elsewhere classified Excludes: complications of surgical and medical care ( ) Child maltreatment syndrome Use additional code(s), if applicable, to identify any associated injuries Use additional E code to identify: nature of abuse (E960-E968) perpetrator (E967.0-E967.9) Child abuse, unspecified Child emotional/psychological abuse Child neglect (nutritional) Use additional code to identify intent of neglect (E904.0,E968.4) Child sexual abuse Child physical abuse Battered baby or child syndrome Excludes: Shaken infant syndrome (995.55) Shaken infant syndrome Use additional code(s) to identify any associated injuries Other child abuse and neglect Multiple forms of abuse Use additional code to identify intent of neglect (E904.0,E968.4) PERSONS WITH A CONDITION INFLUENCING THEIR HEALTH STATUS (V40-V49)

10 Note: V40 These categories are intended for use when these conditions are recorded as "diagnoses" or "problems." Mental and behavioral problems V40.0 Problems with learning V40.1 Problems with communication [including speech] V40.2 Other mental problems V40.3 Other behavioral problems V40.9 Unspecified mental or behavioral problem V58 Excludes: Encounter for other and unspecified procedures and aftercare convalescence and palliative care(v66.0-v66.9) V58.6 Long-term (current) drug use Excludes: drug abuse ( ) drug abuse and dependence complicating pregnancy ( ) drug dependence ( ) hormone replacement therapy (postmenopausal) (V07.4) prophylactic use of agents affecting estrogen receptors and estrogen levels (V07.51-V07.59) V58.61 Long-term (current) use of anticoagulants Excludes: long-term (current) use of aspirin (V58.66) V58.62 Long-term (current) use of antibiotics V58.63 Long-term (current) use of antiplatelets/antithrombotics Excludes: long-term (current) use of aspirin (V58.66) V58.64 Long-term (current) use of non-steroidal anti-inflammatories (NSAID) Excludes: long-term (current) use of aspirin (V58.66) V58.65 Long-term (current) use of steroids V58.66 Long-term (current) use of aspirin V58.67 Long-term (current) use of insulin V58.69 Long-term (current) use of other medications Long term current use of methadone Long term current use of opiate analgesic Other high-risk medications PERSONS ENCOUNTERING HEALTH SERVICES IN OTHER CIRCUMSTANCES (V60-V69) V60 Housing, household, and economic circumstances V60.0 Lack of housing Hobos Social migrants Tramps Transients Vagabonds V60.1 Inadequate housing Lack of heating Restriction of space Technical defects in home preventing adequate care

11 V60.2 Inadequate material resources Economic problem Poverty NOS V60.3 Person living alone V60.4 No other household member able to render care Person requiring care (has) (is): family member too handicapped, ill, or otherwise unsuited to render care partner temporarily away from home temporarily away from usual place of abode Excludes: holiday relief care (V60.5) V61 V60.5 Holiday relief care Provision of health care facilities to a person normally cared for at home, to enable relatives to take a vacation V60.6 Person living in residential institution Boarding school resident V60.8 Other specified housing or economic circumstances V60.81 Foster care (status) V60.89 Other specified housing or economic circumstances V60.9 Unspecified housing or economic circumstance Other family circumstances Includes: when these circumstances or fear of them, affecting the person directly involved or others, are mentioned as the reason, justified or not, for seeking or receiving medical advice or care V61.0 Family disruption V61.01 Family disruption due to family member on military deployment Individual or family affected by other family member being on deployment Excludes: family disruption due to family member on non-military extended absence from home (V61.08) V61.02 Family disruption due to return of family member from military deployment Individual or family affected by other family member having returned from deployment (current or past conflict) V61.03 Family disruption due to divorce or legal separation V61.04 Family disruption due to parent-child estrangement Excludes:other family estrangement (V61.09) V61.05 Family disruption due to child in welfare custody V61.06 Family disruption due to child in foster care or in care of non-parental family member V61.07 Family disruption due to death of family member Excludes: bereavement (V62.82) V61.08 Family disruption due to other extended absence of family member Excludes: family disruption due to family member on military deployment (V61.01) V61.09 Other family disruption Family estrangement NOS V61.1 Counseling for marital and partner problems Excludes: problems related to: psychosexual disorders ( ) sexual function (V41.7) V61.10 Counseling for marital and partner problems, unspecified Marital conflict Marital relationship problem Partner conflict Partner relationship problem

12 V61.11 Counseling for victim of spousal and partner abuse Excludes: encounter for treatment of current injuries due to abuse ( ) V61.12 Counseling for perpetrator of spousal and partner abuse V61.2 Parent-child problems V61.20 Counseling for parent-child problem, unspecified Concern about behavior of child Parent-child conflict Parent-child relationship problem V61.21 Counseling for victim of child abuse Child battering Child neglect Excludes: current injuries due to abuse ( ) Excludes: V61.22 Counseling for perpetrator of parental child abuse counseling for non-parental abuser (V62.83) V61.23 Counseling for parent-biological child problem Concern about behavior of biological child Parent-biological child conflict Parent-biological child relationship problem V61.24 Counseling for parent-adopted child problem Concern about behavior of adopted child Parent-adopted child conflict Parent-adopted child relationship problem V61.25 Counseling for parent (guardian)-foster child problem Concern about behavior of foster child Parent (guardian)-foster child conflict Parent (guardian)-foster child relationship problem V65 V61.29 Other parent-child problems Other persons seeking consultation V65.1 Person consulting on behalf of another person Advice or treatment for nonattending third party Excludes: concern (normal) about sick person in family (V61.41-V61.49) V65.4 Other counseling, not elsewhere classified Health: advice education instruction Excludes: counseling (for): contraception (V25.40-V25.49) genetic (V26.31-V26.39) on behalf of third party (V65.11, V65.19) procreative management (V26.41-V26.49) V65.40 Counseling NOS V65.49 Other specified counseling V71 Observation and evaluation for suspected conditions not found Excludes: suspected maternal and fetal conditions not found (V89.01-V89.09)

13 Note: This category is to be used when persons without a diagnosis are suspected of having an abnormal condition, without signs or symptoms, which requires study, but after examination and observation, is found not to exist. This category is also for use for administrative and legal observation status. V71.0 Observation for suspected mental condition V71.02 Childhood or adolescent antisocial behavior Dyssocial behavior or gang activity in child or adolescent without manifest psychiatric disorder V71.09 Other suspected mental condition Abstracted from International Classification of Diseases, 9 th revision, Clinical Modification, issued by the US Department of Health and Human Services. Available in electronic versions from Published copies of ICD-9-CM are available from a variety of sources and should be found in any medical library. From the ( 2010