Wiki Diagnoses Reported by Patient/Parent

[alvesey]

I have just started coding for a mental health provider who told me that she will use "personal history" in her code description if the patient insists they have been diagnosed with it. For example, a mother will insist that their child has oppositional defiant disorder, but the provider is not seeing it in her interactions with the child. I assume that this would not be a reportable code, unless she had old records from another provider. By the way, this came up because she had noted "personal history of ODD" next to ICD-10 code F91.3. I advised her that F91.3 is for a current, active diagnosis of ODD and that this would fall under Z86.59, if it is not an active diagnosis.

Am I correct in my assumption that Z86.59 does not include patient-reported only history?

Thanks!

 

[Munzueta]

First thing, hope you are enjoying the coding for mental health.

Second, we cannot code from patients/parents statements, it's a little more frequent to see this type of cases with behavioral cases, since patients believe they have something going on. I had a case where the patient was completely sure that he was diabetic and needed insulin, but the provider did not give a diagnosis of diabetes because there was no clinical factors to support it as the patient was good in his glucose levels.

If its not documented, it never happened, so in other words, you have to find proper documentation that this patient had a prior history of ODD or that it was truly diagnosed by the provider.

I got a little confuse when you said "she had noted personal history of ODD", who is she? the parent or the provider?

 

[alvesey]

Thank you for confirming what I was thinking regarding patient/parent reported diagnoses. I'm sorry for the confusion, as it was the provider who had noted "personal history of ODD". I think the provider thought that "personal history" meant "personally reported by the patient". Now that I have explained that it is meant to differentiate a patient's history from his/her family history, she doesn't use it any longer.

Thanks again for your help!

 

[Munzueta]

Yes definitely inform your provider about that statement, since that is representing that there is a history of ODD as per the statement provided.

Have a good one!