Wiki Coding Behavioral Health

[tlindo1]

I need assistance with the ICD 10 coding for Psych notes and Diagnostic Evaluation Medical. Do you code the Z codes from the notes? For example if the patient has a history of physical or sexual abuse even if it is not listed in the diagnosis list? If the MD diagnoses PTSD and does not diagnosis the history codes but it is talked about in the notes, do you code it?

 

[Williamsad78]

I only add the Z codes for Family Hx of and Hx of self-harm codes. If the provider does not add the PTSD in the patient's history, they may be following the symptoms to confirm the dx and the cause like hx of physical or sexual abuse. I only add those when it's documented as confirmed or suspected abuse codes in final dx. Now, on a follow up if the provider prescribes a medication for a diagnosis and it's documented previously I do add that for the date of service. Or if it is a New Eval from an ER/Inpatient hospital and it is documented there we can use it. It's best to ask the provider to add it, specify the type and perpetrator and follow it for the payer as some require it for coverage, and you may not have that detail on the follow-up if they don't continue with the dx. A simple query to the provider may answer your question on the additional dx.