Wiki Help with Diagnosis Coding

[ckeeney]

I need some input on how to code the following:
Patient was seen by a psychiatrist for audio and tactile hallucinations.
Reported principal diagnosis by the provider is F06.0 - Psychotic disorder with hallucinations due to known physiologic condition.
For the underlying conditions the provider states "status post major surgery, medications, recurrent UTI's". As far as I can find, there is no code for "status post major surgery) nor is there a direct link that the hallucinations are a complication. In the note there is mention of prescribed opioid medications that patient states is not taking. Also in the note there is documentation of prophylactic antibiotics for the recurrent UTI's.
I have reached out to the provider, but any thoughts on how to code this would be appreciated.

 

[BrittanyDee]

Z98.890- is "other specified post procedural states" but it seems like they provider is correlating maybe the UTI's with the hallucinations? I think a provider query would be ideal.

 

[sls314]

EncoderPro lists this lay description for F06.0:

"Hallucinations are the perception of an event involving sight (visual hallucination), hearing (auditory hallucination), smell, taste, or touch (tactile hallucination) in the absence of an actual event. Hallucinations are caused by irritation or activation of neural pathways responsible for all of the senses. Physiological conditions that may cause hallucinations include diseases of the brain, such as infection or inflammation, vascular disease, brain tumors, or epilepsy, as well as exposure to toxic substances and other acute or chronic diseases affecting other body systems."

Although you can find post surgical Z codes, I don't think they'd be appropriate to use as support for F06.0.

Keep in mind that your provider may have selected the wrong diagnosis code. What specifically does the documentation state about the hallucinations? If the hallucinations are a disorder specifically linked to a known physiological condition, the provider should have specifically stated that.

Otherwise, if the patient is having a symptom of hallucinations and the definitive cause is unknown, perhaps one of the symptom codes from R44.- would be more appropriate?

Edit to add: It all depends on how the documentation is worded, of course. I only mention the symptom code as a possibility. Physicians are the clinical experts, but often have less knowledge about proper code selection to match their documentation.

 

[ckeeney]

EncoderPro lists this lay description for F06.0:

"Hallucinations are the perception of an event involving sight (visual hallucination), hearing (auditory hallucination), smell, taste, or touch (tactile hallucination) in the absence of an actual event. Hallucinations are caused by irritation or activation of neural pathways responsible for all of the senses. Physiological conditions that may cause hallucinations include diseases of the brain, such as infection or inflammation, vascular disease, brain tumors, or epilepsy, as well as exposure to toxic substances and other acute or chronic diseases affecting other body systems."

Although you can find post surgical Z codes, I don't think they'd be appropriate to use as support for F06.0.

Keep in mind that your provider may have selected the wrong diagnosis code. What specifically does the documentation state about the hallucinations? If the hallucinations are a disorder specifically linked to a known physiological condition, the provider should have specifically stated that.

Otherwise, if the patient is having a symptom of hallucinations and the definitive cause is unknown, perhaps one of the symptom codes from R44.- would be more appropriate?

Edit to add: It all depends on how the documentation is worded, of course. I only mention the symptom code as a possibility. Physicians are the clinical experts, but often have less knowledge about proper code selection to match their documentation.

Yes, I thought about the R44.- codes rather than the F06.0 The provider states in the note: " ... who is experiencing visual and tactile hallucinations after second back surgery. Most likely has a psychotic disorder due to a known physiological disorder, status post back surgery, recurrent UTI's, and medications used for her treatment." The 'most likely' leads me to the signs/symptoms code. Also, very few codes outside of the mental health chapter are readily available in our EMR (the others are listed as "medical" codes and would only show if they searched under this category instead of the DSM-5 diagnoses so it ends up being a manual code entry by me). I have reached out to the provider.

Thank you for your thoughtful reply.