Help with Psych ICD-9 Sequencing & COnsults

crystallena

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I am a coding compliance auditor (no boos, please!) and I have recently inherited a psychiatry group. I have absolutely no experience with psych coding at all, and the availablity of any resources on the subject are positively underwhelming! I have 1 main question: Our psychiatrists do a lot of consults for mental health stability as part of a pre-organ transplant work up. Prior to the big CMS Consultation exclusion, they billed a consult. Now, however, they bill either a 90801 for outpatient, and initial hospital care for inpatient. My question is this: When it comes to sequencing the diagnosis, usually we have the Medical problem, or multiple medical problems (which falls under Axis III) and occasionally, there is an axis I diagnosis such as depression, anxiety, or adjustment reaction. Normally, we would use the Axis I diagnosis as the primary, and only code for the Axis III issues if the psychiatrist is managings those comorbidies, or, managing drugs. In the case of these consults, when the primary reason for the encounter is because of the medical diagnosis, and the Depression, anxiety, et al, are secondary to the medical diagnosis, which should be coded first?

Any assitance will be greatly appreciated and will result in a little more peace in the world....

Thanks,
Crystal Chamburs-Garcia, CPC
 

kevbshields

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Who'd boo a coding compliance auditor?! They keep us all on track.

Under normal circumstances, you'd want to sequence your mental health diagnoses first--in a manner fitting the "first-listed" diagnosis rules in ICD-9. That means whatever condition the patient has that was the clinical focus of the visit or encounter is sequenced before others, chapter-specific ICD-9 guidelines may apply.

You mention these are for pre-organ transplant purposes (at least sometimes). That makes me believe the V72.8X series might be most appropriate for your primary diagnosis on those cases. The service (from what I'm gathering) seems to be pre-operative in nature and concerning the patient's capacity to tolerate the rigors of the physical transplant.

On the other hand, you mention the psychiatrists seeing patients "with a medical diagnosis." Although that is the case, I'm led to believe psychiatrists are unlikely to manage those medical conditions as primary. Their scope of practice would impact the selection of your primary dx--make sense? As consultants or clinical managers of the patient's psychiatric conditions, and in rendering a psychiatric service to these patients, I would expect to see a mental health dx listed before any medical conditions, unless otherwise advised through ICD-9 coding rules.

Keep in mind, there are dx in the Mental Health Disorders chapter that read "secondary to a general medical condition." (See 293.0, though that is not the best example and I am relying on memory here). Those may be more appropriate in some instances.

Definitely get a copy of DSM-IV-TR. Although we code in ICD-9 and follow its rules, DSM is very helpful when you're trying to sort out diagnostic issues related to mental and behavior health medical necessity.

Good luck and I hope this has assisted you in some way!
 
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crystallena

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Thank you Kevin, I just realized I never properly thanked you before. I actually came across your article, "DSM-IV to ICD-9-CM An Uneven path" and it also helped me greatly in this new world (to me, anyway) of coding. I appreciate you!
 
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