ICD 10 Coding Alert

Watch for specificity in documentation to select the most granular code listed for substance abuse related visits.

A big challenge in coding for mentally ill ED patients is assigning a diagnosis based on the ED presentation and the current mental status of the patient while that are in the ED setting. That diagnosis assignment can be even harder with the increased specificity ICD-10 will bring next year.

Read on for these insider tips on coding mental disorders from Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC, AHIMA Certified ICD-10 Instructor and President, Edelberg Compliance Associates so you’re up to speed before the Oct. 1, 2014 deadline.

First, Identify The Source Of The Presenting Problem

Mental disorders seen in the emergency department, many relate to dementia, substance abuse, non-mood psychotic disorders, and anxiety disorders. These diagnosis categories appear in Chapter 5 - Mental and Behavioral Disorders (F01-F99) of the ICD-10 coding book.

This chapter of ICD-10 includes the following classifications to guide your code choice:

• Mental disorders due to psychological conditions
• Mental and behavioral disorders due to psychoactive substance use
• Schizophrenia, schizotypal, delusional, and other non-mood psychotic disorders
• Mood affective disorders
• Anxiety, dissociative, stress-related, somotoform and other nonpsychotic mental disorders
• Behavioral syndromes associated with physiological disturbances and physical factors
• Disorders of adult personality and behavior
• Intellectual disabilities
• Pervasive and specific developmental disorders
• Behavioral and emotional disorders with onset usually occurring in childhood and adolescence
• Unspecified mental disorders

Code the Underlying Condition First

Mental disorders due to a psychological condition include dementia, so you would code the underlying physiological condition first, such as Alzheimer’s (G30.-); Parkinson’s Disease (G20.-); and Intoxications (T36-T65). Unspecified dementia is differentiated between dementia with or without behavioral disturbance, Edelberg explains.

Alcohol and other substance abuse are differentiated from dependence and the physician must carefully document to support the appropriate coding of these abuse disorders. You may be struggling with caring for an intoxicated patient but for ICD-10 purposes, alcohol abuse is differentiated from alcohol dependence. Alcohol abuse is divided into a number of separate descriptive elements and that distinction will guide your code assignment, says Edelberg.

Options for ICD-10 include:

• abuse uncomplicated
• abuse w/intoxication uncomplicated
• w/intoxication delirium
• w/intoxication unspecified
• w/alcohol-induced mood disorder
• w/psychotic disorder (delusions, hallucinations, psychotic disorder, unspecified);
• with other alcohol induced disorders (anxiety disorder, sexual dysfunction, sleep disorder, other disorders NOS)

Is It Abuse or Dependence? Check the Documented History For The Answer

There are unique codes for alcohol and drug use (not specified as abuse or dependence), and abuse and dependence. And there are changes to drug and alcohol abuse and dependence as they no longer identify continuous or episodic use. A history of drug or alcohol dependence is coded as ‘in remission.’ There is a code for blood alcohol level (Y90.-) that can be assigned as an additional code when the documentation indicates its use, says Edelberg.

Be Sure To Pick The Right Category Of The Substance Being Abused

ICD-10 includes the specific category of commonly abused substances. For example if college student is brought in by his roommate because he had been taking drugs that produced bizarre behavior and reported hallucination, you can identify the category of substance abuse with a diagnosis such as F16.951 (Hallucinogenic use, unspecified with hallucinogen-induced psychotic disorder with hallucinations).

Additional categories for substance abuse include:

• Opioid related disorders related to abuse, dependence or unspecified;
• Cannabis disorders related to abuse, dependence or unspecified,
• Sedative, hypnotic, or anxiolytic related disorders from abuse, dependence,
• Sedative, hypnotic or anxiolytic dependence with OTHER sedative, hypnotic or anxiolytic-induced disorders
• Sedative, hypnotic or anxiolytic-related drug use, unspecified
• Cocaine abuse, dependence, unspecified.
• Other stimulant related disorders
• Hallucinogen related disorders (abuse, dependence, unspecified)
• Hallucinogen use
• Nicotine dependence
• Inhalant related disorders (dependence, psychotic disorder, unspecified)
• Other psychoactive substance abuse disorders

Don’t Let Coding For Depression Get You Down

Mood affective disorders such will require differentiation as to whether it is a single or recurrent episode and the severity of the episode is mild, moderate or severe. For example unspecified depression is coded as depression NOS, depressive disorder NOS and major depression, NOS. Depressive disorders are distinguished by single episode major depressive disorder, major depressive disorder recurrent, major recurrent in remission, persistent mood (affective) disorder and unspecified mood (affective) disorder. Detailed documentation of the patient’s depressive condition will be required when known. For example is the major depressive singe episode codes require a 4th digit to determine whether they are unspecified, mild moderate or severe, Edelberg adds.

Examples:

• F32.0, Major depressive disorder, single episode, mild
• F32.1, Major depressive disorder, single episode, moderate
• F32.2, Major depressive disorder, single episode, severe without psychotic features

Choosing the Right Pain Code Need Not Be A Huge Headache

The reasons many patients present to the ED is because of the pain caused by the actual medical condition involved. Chapter 6 - Diseases of the Nervous System (G00-G99) covers pain codes and other neurological diseases treated in the ED including:

Inflammatory diseases of the central nervous system

• Systemic atrophies affecting the nervous system
  
• Extrapyramidal and movement disorders
  
• Degenerative diseases of the nervous system,
  
• Demyelinating diseases of the central nervous system
  
• Episodic and paroxysmal disorders,
  
• Nerve, nerve root and plexus disorders,
  
• Polyneuropathies and other disorders,
  
• Diseases of myoneural junction and muscle,
  
• Cerebral palsy and other paralytic syndromes
  
• Other disorders including pain
  

Do You have A Dominate Side?

Consider a patient presenting with hemiplegia or hemiparesis, with ICD-10 you’ll need to know whether the dominant or non-dominant side is affected. You’ll also want to designate the limb or limbs affected using codes such as G83.1- (Monoplegia of lower limb) or G83.2- (Monoplegia of upper limb). If the affected side is noted but not whether that side is dominant, and the classification system does not indicate a default, select a code using the following rules, says Edelberg:

• If the right side is affected the default is dominant
• If the left side is affected, the default is non-dominate
• For ambidextrous patients, the default should be dominant

Take Two Aspirin And Apply This Advice for Reporting Pain

The codes identifying the site of the pain are found in Chapter 18, but Chapter 6 covers pain not elsewhere classified. If documented as acute or chronic, category G89 (Pain not elsewhere classified) is appropriate. However, if the encounter is for other than pain control or pain management without a definitive diagnosis, assign a code for the site of the pain first followed by a code from the G89 category. Chronic pain is reported with G89.2, but it requires specific documentation that the pain is, indeed, chronic. There is no time frame for classifying pain as chronic, Edelberg explains.

Seize These Tips for Epilepsy Diagnoses

ICD-10 updates the terminology for epilepsy, with terms to classify the disorder such as localization related idiopathic epilepsy, generalized idiopathic epilepsy and special epileptic syndromes.

Within those various categories, more specificity is possible, such as identifying seizures of localized onset, complex partial seizures, intractable and status epilepticus, says Edelberg. A note within category G40 (Epilepsy and recurrent seizures) provides the following terms to be considered equivalent to intractable:

• Pharmaco resistant (pharmacologically resistant)
• Treatment resistant
• Refractory (medically)
• Poorly controlled

Common ED Examples Are:

• G40.909 (Epilepsy, unspecified, not intractable, without status epilepticus)
• G45.9 (Transient cerebral ischemic attack, unspecified).