mental capacity to make medical decisions

[mjl903]

I am coding Psychiatry Emergency Services and came across a note where the pt needs to be admited into the hospital for a medical condition however the pt is refusing. The pt is sent to PES to evaluate the capacity for refusal of treatment.

I know the cpt code, but what would the ICD 9 code for capacity or lack of?

If the pt does not have the capacity, I can code the mental disorder(s) but what about the incapacity itself, I was given V71.09, but I was wondering if there was any other code I can use?

And what if the patient has the capacity to make the decision and no mental disorders are found?

Thank you!!

[hewitt]

You might want to consider 780.97. I'm sure you know that usually the change in metal status is usually linked to a specified medical condition, but this can be used. If no mental disorder is found, then I would just code the chief complaint, unless the medical note gave more detail.