DSM ICD. Chapter Specific Coding Guidelines 2/17/2014. Chapter 5 Mental, Behavioral, and Neurodevelopmental Disorders (F01 F99)

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1 Chapter Specific Coding Guidelines Chapter 5 Mental, Behavioral, and Neurodevelopmental Disorders (F01 F99) 2 main sets of diagnostic classifications for Mental, Behavioral, and Neurodevelopmental Disorders ICD International Classification of Disease DSM Diagnostic and Statistical Manual of Mental Disorders Classification: ICD DSM Developed by: Purpose: World Health Organization (WHO) Official diagnostic coding system in the US used for reporting and identifying the reason for the visit American Psychiatric Association (APA) A provider s guide used for identifying and determining a diagnosis Composed of: Physical and mental disorders Only mental disorders Content: List codes without including the diagnostic criteria for code selection Contain the diagnostic criteria for code selection Structure: Divided into 10 sections Divided into 16 chapters 1

2 This chapter contains the following blocks: F01 F09 Mental disorders due to known physiological conditions F10 F19 Mental and behavioral disorders due to psychoactive substance use F20 F29 Schizophrenia, schizotypal, delusional, and other non mood psychotic disorders F30 F39 Mood [affective] disorders F40 F48 Anxiety, dissociative, stress related, somatoform and other nonpsychotic mental disorders F50 F59 Behavioral syndromes associated with physiological disturbances and physical factors F60 F69 Disorders of adult personality and behavior F70 F79 Intellectual disabilities F80 F89 Pervasive and specific developmental disorders F90 F99 Behavioral and emotional disorders with onset usually occurring in childhood and adolescence Pain disorders related to psychological factors F45. 4 Pain disorders related to psychological factors Excludes 1 pain NOS (R52) F45.41 Pain disorder exclusively related to psychological factors Somatoform pain disorder (persistent) (*the Excludes 1 note under G89. indicate that it should not be used with F45.41*) F45.42 Pain disorder with related psychological factors Code also associated acute or chronic pain (G89. ) Please notice the difference 2

3 Mental and behavioral disorders due to psychoactive substance abuse Selection of remission requires the provider s clinical judgment Assigned only based on the provider s documentation Remission DSM V ICD 10 In early remission In sustained remission in remission Selection of in remission for codes F10 F19 ( due to psychoactive substance use) is coded as.21 Alcohol dependence Excludes1: alcohol abuse (F10.1 ) alcohol use, unspecified (F10.9 ) Excludes2: toxic effect of alcohol (T51.0 ) F10.20 Alcohol dependence, uncomplicated F10.21 Alcohol dependence, in remission 3

4 Use vs. Abuse vs. Dependence A definite diagnosis of dependence should usually be made only if three or more of the following have been present together at some time during the previous year: A strong desire or sense of compulsion to take the substance; Difficulties in controlling substance taking behavior in terms of its onset, termination, or levels of use; A physiological withdrawal state when substance use has ceased or have been reduced, as evidenced by: the characteristic withdrawal syndrome for the substance; or use of the same (or closely related) substance with the intention of relieving or avoiding withdrawal symptoms; Evidence of tolerance, such that increased doses of the psychoactive substance are required in order to achieve effects originally produced by lower doses (clear examples of this are found in alcohol and opiate dependent individuals who may take daily doses sufficient to incapacitate or kill nontolerant users); Progressive neglect of alternative pleasures or interests because of psychoactive substance use, increased amount of time necessary to obtain or take the substance or to recover from its effects; Persisting with substance use despite clear evidence of overtly harmful consequences, such as harm to the liver through excessive drinking, depressive mood states consequent to periods of heavy substance use, or drug related impairment of cognitive functioning; efforts should be made to determine that the user was actually, or could be expected to be, aware of the nature and extent of the harm. The diagnosis requires that actual damage should have been caused to the mental or physical health of the user. Harmful patterns of use are often criticized by others and frequently associated with adverse social consequences of various kinds. The fact that a pattern of use or a particular substance is disapproved of by another person or by the culture, or may have led to socially negative consequences such as arrest or marital arguments is not in itself evidence of harmful use. Acute intoxication, or hangover is not in itself sufficient evidence of the damage to health required for coding harmful use. Harmful use should not be diagnosed if dependence syndrome, a psychotic disorder, or another specific form of drug or alcoholrelated disorder is present. 4

5 Abuse Dependence Alcohol Abuse Disorder Severe Moderate Mild Presence of 6 or more symptoms Presence of 4 5 symptoms Presence of 2 3 symptoms Essential feature: Problematic pattern of alcohol use leads to clinically significant distress or impairment At least two of the following in a 12 month period: 1. Taken in larger amounts or over a longer period of time than intended 2. Persistent desire or efforts to cut down or control use 3. Much time taken obtaining using or recovering from substance 4. Cravings or a strong desire or urge to use a substance (new criteria) 5. Recurrent use resulting in failure to fulfill role obligation (work, school, or home) 6. Continued used despite social and interpersonal problems 7. Social, occupational, or recreational activities reduced due to alcohol 8. Recurrent use in hazardous situations 9. Continued use despite physical or psychological problems due to substance 10. Tolerance 11. Withdrawal Specifiers: Early remission, Sustained remission, and In controlled environment Severity: Mild, Moderate, or Severe ICD 10 CM F10 10 Alcohol abuse, uncomplicated DSM V F10.10 Alcohol Use Disorder, Mild F10.20 Alcohol dependence, uncomplicated F10.20 Alcohol dependence, uncomplicated F10.20 Alcohol Use Disorder, Moderate F10.20 Alcohol Use Disorder, Severe 5

6 Cannot be coded together Dependence Abuse Use If both are document Code as Use Abuse Abuse If both are document Code as Abuse Dependence Dependence 6

7 If both are document Code as Use Dependence Dependence If all three are document: Abuse Use Dependence Code as Dependence MENTAL, BEHAVIORAL AND NEURODEVELOPMENTAL DISORDERS (F01 F99) Additional Changes 7

8 Change in terminology... Intellectual Disabilities (F70 F79) Code first any associated physical or developmental disorders Excludes1: borderline intellectual functioning, IQ above 70 to 84 (R41.83) F70 Mild intellectual disabilities IQ level to approximately 70 Mild mental subnormality F71 Moderate intellectual disabilities IQ level to Moderate mental subnormality F72 Severe intellectual disabilities IQ to Severe mental subnormality F73 Profound intellectual disabilities IQ level below Profound mental subnormality F78 Other intellectual disabilities F79 Unspecified intellectual disabilities Mental deficiency NOS Mental subnormality NOS Previously known as Mental Retardation ICD 10 CM F84.0 Childhood autism Infantile autism Infantile psychosis Kanner s syndrome Excludes1: Asperger s syndrome (F84.5) F84.5 Asperger s syndrome Asperger s disorder Autistic psychopathy Schizoid disorder of childhood DSM V F84.0 Autism Spectrum Disorder (Encompasses autism disorder, Asperger s disorder, and pervasive developmental disorder NOS) Specifiers: With or without accompanying intellectual impairment With or without accompanying language impairment Associated with a known medical or genetic condition or environmental factor Associated with another neurodevelopmental, mental, or behavioral disorder With catatonia Coding Challenges 8

9 Case: A 26 year old male was taken to the emergency department by the local sheriff after the patient became disruptive in a local nightclub. The patient tested positive for cocaine, and alcohol. The patient was diagnosed with alcohol abuse, which was uncomplicated, and cocaine abuse with cocaine induced mood disorder. Diagnoses: F Alcohol abuse with intoxication, uncomplicated F14.14 Cocaine abuse with cocaine induced mood disorder Y90.9 Presence of alcohol in blood, level not specified Patient is a 55 year old female who lost her husband eight months ago in an industrial accident. She was released from the hospital three weeks ago due to suicide attempt. She is suffering from a moderate major depressive disorder, which is recurrent. At that time, the patient stated she no longer wished to live without her spouse. She has been monitored once per week since her release. Last visit, her medications were slightly changed. Patient states she is feeling better and her mood is improving. She has no current thoughts of suicide. 9

10 Diagnosis: F33.1 Major depressive disorder, recurrent, moderate References AMA The Complete Official Draft Code Set ICD 10 CM 2014 AHIMA ICD 10 CM Overview: Deciphering the Code PCnm9hqHvXopURNr CnTxT Frame Setup IndFrame retrieve coursework H0ICD10OVER%5F13 ContFrame Info Class D0 APA Diagnostic and Statistical Manual of Mental Disorders Fifth Edition CMS 2014 ICD 10 CM and GEMs ICD 10 CM and GEMs.html Grider, D., Preparing for ICD 10 CM: Make the Transition Manageable Grider, D., Principles for ICD 10 CM Coding Workbook World Health Organization Website 10

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