Put Aside Your ICD-10-CM Anxiety Coding Worries
Look to DMS-5 for clarity on various anxiety disorders.
Proper documentation of anxiety disorder is the key for capturing the patient’s condition accurately in ICD-10-CM. Here’s the diagnostic information you should be looking for.
Anxiety disorders are a class of mental disorders that distinguish themselves from other problems with two key features: fear and anxiety. Anxiety is defined as “anticipation of future threat.” Fear is an emotion experienced in response to an imminent threat (real or imagined).
In the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), the chapter on anxiety disorders was separated into three categories:
- Anxiety disorders (separation anxiety disorder, selective mutism, specific phobia, social phobia, panic disorder, agoraphobia, and generalized anxiety disorder).
- Obsessive-compulsive related disorders (OCRD) (obsessive-compulsive disorder, body dysmorphic disorder, hoarding disorder, trichotillomania, and excoriation disorder).
- Trauma and stressors-related disorders (reactive attachment disorder, disinhibited social engagement disorder, post-traumatic distress disorder (PTSD), acute stress disorder, and adjustment disorder).
OCRD and PTSD are no longer classified under anxiety disorder in DSM-5 (as they were in DSM-IV). Although anxiety remains a key feature in OCRD and PTSD, there are enough differences between the three types of mental disorder, and enough differences within each type of disorder, to justify three separate chapters.
Types of Anxiety Disorder
Separation anxiety disorder – excessive distress when experiencing or anticipating separation from home or losing major attachment to an individual.
Selective mutism – individuals who fail to speak during a social interaction but speak normally at home with close significant others. Failure to interact is due to high social anxiety.
Specific phobia – irrational fear of something that causes anxiety. This could come from animal phobias, natural environment phobias, blood-injection-injury phobias, situational phobias, and other phobias.
Social anxiety disorder (social phobia) – fear or anxiety of possible scrutiny, criticism, and rejection from others that causes the individual to avoid social or performance situations.
Panic disorder – recurrent, unexpected panic attacks that, according to DSM-5, are characterized by four or more of the following symptoms: palpitations, pounding heart, or accelerated heart rate; sweating; trembling or shaking; sensations of shortness of breath or smothering; a feeling of choking; chest pain or discomfort; nausea or abdominal distress; feeling dizzy, unsteady, lightheaded, or faint; feelings of unreality (derealization) or being detached from oneself (depersonalization); fear of losing control or going crazy; fear of dying; numbness or tingling sensations (paresthesia), and chills or hot flushes.
Agoraphobia – fear of places where escape could be difficult, or help is not available if something untoward happens. A person with this condition can feel helpless and trapped in crowded areas.
Generalized anxiety disorder (GAD) – despite the name, GAD is a specific type of anxiety disorder, identified by excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least six months. GAD can cause significant distress or impairment in social, occupational, or other important areas of functioning. No underlying cause or condition is associated such as side-effects of substances or other medical condition.
A person may have multiple anxiety disorders. Proper diagnosis coding requires understanding how the various anxiety disorders are defined.
F93.0 Separation anxiety disorder of childhood and F94.0 Selective mutism were formerly classified as childhood disorders. They are now part of anxiety disorder for which both children and adults can be diagnosed, so the diagnostic criteria no longer specify that onset must be before age 18 years.
F41.0 Panic disorder and F40.0x Agoraphobia are now unlinked and form two diagnoses with separate criteria because not everyone who has agoraphobia also has panic attacks. Panic disorder with agoraphobia occurs in approximately two-thirds of cases, and is reported using F40.01 Agoraphobia with panic disorder.
F41.9 Anxiety disorder, unspecified applies to symptoms characteristic of an anxiety that do not meet the full criteria for any of the disorders in the anxiety disorders diagnostic class. This code is used when the clinician does not specify the reason the criteria are not met for a specific anxiety disorder and there is insufficient information to make a more specific diagnosis (e.g., in the emergency room).
Example Scenario 1:
A 30-year-old male with past medical history of asthma, separation anxiety disorder, and PTSD presents to the emergency department (ED) due to sudden onset of chest pain with lightheadedness and fainting. Symptoms began while watching a movie inside a theater. Patient denies history of heart disease. He is accompanied with his wife and children. Chest pain does not radiate, is not pleuritic in nature but with feeling of tightness and choking. Patient appears agitated and restless. Patient is compliant with his medications. The ED provider diagnoses him with anxiety. ICD-10-CM coding:
J45.909 Unspecified asthma, uncomplicated
F43.10 Post-traumatic stress disorder, unspecified
Example Scenario 2:
A 45-year-old male patient comes in complaining about his episodes of feeling excessive agitation with palpitations, difficulty breathing, and sweating. These symptoms occur with a sudden feeling of being closed in every time he goes to public places. No other significant medical history is noted. Physician diagnosed panic disorder with agoraphobia. ICD-10-CM coding:
DSM-5 allows clinicians to diagnose mental disorders more accurately and ICD-10-CM enables coders to code with much more specificity. The result is quality data that will drive improved outcomes for patients.
About the author:
Angelica Mae Celis-Duran, RN, CPC, CPMA, BCHH-C, has been coding for seven years, working with inpatient, outpatient, and hierarchical condition category coding, as well as Healthcare Quality Patient Assessment Form, home health, and evaluation and management coding. She was a trainer for a home health account. Celis-Duran is a quality control analyst for the ED of Armco Healthcare Services Inc. She is a member of the Makati, Philippines, local chapter.
The New DSM-5: Anxiety Disorders and Obsessive-Compulsive Disorders: www.mentalhelp.net/articles/the-new-dsm-5-anxiety-disorders-and-obsessive-compulsive-disorders/
Goldman-Luthy, MD, MRP, FAAP, Jennifer. Anxiety Disorders: www.medicalhomeportal.org/diagnoses-and-conditions/anxiety-disorders
Generalized Anxiety Disorder: https://images.pearsonclinical.com/images/assets/basc-3/basc3resources/DSM5_DiagnosticCriteria_GeneralizedAnxietyDisorder.pdf
Unspecified Anxiety Disorder Symptoms and Related DSM–5 Diagnosis: http://seniorcarepsychological.com/unspecified-anxiety-disorder-symptoms-and-related-dsm-5-diagnosis/
Highlights of Changes from DSM-IV-TR to DSM-5: American Psychiatric Association: www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM_Changes_from_DSM-IV-TR_-to_DSM-5.pdf
Bandelow, Borwin. Research Gate, Comparison of the DSM-5 and ICD-10: Panic and Other Anxiety Disorders (February 2017). CNS Spectrums. 1-3. 10.1017: www.researchgate.net/publication/313494606_Comparison_of_the_DSM-5_and_ICD-10_panic_and_other_anxiety_disorders