Copyright © 2016 AAPC

Coding for PsychologyAnnie Boynton, BS, RHIT, CPCO, CPC, CCS, COC, CCS-P, CPC-P. CPC-I

Before we begin• What will not be discussed

• Local, state, federal guidelines• Understand the terminology

• Ask questions• Will not be able to address in detail each slide

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Key Terms

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• All of these phrases and terms will take on more meaning as we look at diagnosis codes and the CPT codes associated with this most interesting branch of medicine.

• Psychiatry• Psychology• Psychosis

Psychiatry - What is it?

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• Psychiatry –• Branch of medicine that deals with the diagnosis,

treatment, prevention and study of mental disorders. • Unlike other branches of medicine it may be difficult to

readily identify the cause of a mental disorder. • These disorders are not necessarily picked up on a

radiological exam or even during a diagnostic endoscopic procedure.

Psychology - What is it?

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• Psychology –• Branch of science that deals with mental processes

whether the process is considered normal or abnormal and how that process affects behavior.

• Typically when a patient presents for therapy the time is spent in discussing ways to process information so that behaviors do not get out of hand.

Psychosis - What is it?

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• Psychosis –• Often the term psychosis is also used when describing

patients with a mental disorder. • However, over time this term is now reserved for

patients with a disorder that is so severe that they experience personality disintegration and a loss of a sense of reality.

• This is often seen in severe cases of schizophrenia

• Most of the codes for conditions that would be related to mental disorders will be found in chapter 5 of ICD10.

• These are the F codes.

Chapter 5: Mental, Behavioral and Neurodevelopmental disorders (F01 – F99)

Diagnoses

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ICD-9 vs. ICD-10

• The chapter that dealt with mental disorders in ICD-9 had only 30 three-character condition categories (290-319);

• Chapter 5 (F codes) of ICD-10 has 100 such categories.

Chapter 5• F01-F09 Mental disorders due to known physiological conditions

• F10-F19 Mental and behavioral disorders due to psychoactive substance use

• F20-F29 Schizophrenia, schizotypal, delusional, and other non-mood psychotic disorders

• F30-F39 Mood [affective] disorders

Chapter 5• F40-F48 Anxiety, dissociative, stress-related, somatoform and

other nonpsychotic mental disorders

• F50-F59 Behavioral syndromes associated with physiological disturbances and physical factors

• F60-F69 Disorders of adult personality and behavior

• F70-F79 Intellectual disabilities

Chapter 5

• F80-F89 Pervasive and specific developmental disorders• F90-F98 Behavioral and emotional disorders with onset

usually occurring in childhood and adolescence• F99 Unspecified mental disorder

Chapter 5 - Terminology"Psychotic" has been retained as a convenient descriptive term, particularly in F23, Acute and transient psychotic disorders. • Its use does not involve assumptions about psychodynamic mechanisms, but

simply indicates the presence of hallucinations, delusions, or a limited number of severe abnormalities of behavior, such as gross excitement and over activity, marked psychomotor retardation, and catatonic behavior.

Chapter 5 - Terminology

Disorder • The term "disorder" is used throughout the classification, so as to avoid even

greater problems inherent in the use of terms such as "disease" and "illness".• "Disorder" is not an exact term, but it is used here to imply the existence of a

clinically recognizable set of symptoms or behavior associated in most cases with distress and with interference with personal functions.

• Social deviance or conflict alone, without personal dysfunction, should not be included in mental disorder as defined here.

Chapter 5 - Terminology• The term "psychogenic" has not been used in the titles of categories, in view

of its different meanings in different languages and psychiatric traditions. • It still occurs occasionally in the text, and should be taken to indicate that the

diagnostician regards obvious life events or difficulties as playing an important role in the genesis of the disorder.

Chapter 5 - Terminology• The terms "impairment", "disability" and "handicap" are used according to the

recommendations of the system adopted by WHO.• Occasionally, where justified by clinical tradition, the terms are used in a

broader sense.

Chapter 5F01-F09 Mental disorders due to known physiological conditions

• F01 – Vascular Demetria• F02 – Dementia in disease classified elsewhere• F03 – Unspecified Dementia• F04 - Amnestic disorder due to known physiological condition• F05 - Delirium due to known physiological condition• F06 - Other mental disorders due to known physiological condition• F07 - Personality and behavioral disorders due to known physiological condition• F09 - Unspecified mental disorder due to known physiological condition

Mental disorders due to known physiological condition (F06)Code first the underlying physiological condition

• F06.0 Psychotic disorder with hallucinations due to known physiological condition

• F06.1 Catatonic disorder due to known physiological condition • F06.2 Psychotic disorder with delusions due to known physiological

condition

Mental disorders due to known physiological condition (F06)• F06.30 Mood disorder due to known physiological condition, unspecified • F06.31 Mood disorder due to known physiological condition with depressive

features • F06.32 Mood disorder due to known physiological condition with major

depressive-like episode • F06.33 Mood disorder due to known physiological condition with manic

features • F06.34 Mood disorder due to known physiological condition with mixed

features • F06.4 Anxiety disorder due to known physiological condition • F06.8 Other specified mental disorders due to known physiological condition

Chapter 5F10-F19 Mental and behavioral disorders due to psychoactive

substance use

Chapter 5C. Mental and behavioral disorders due to psychoactive substance use

2) Psychoactive Substance Use, Abuse And Dependence When the provider documentation refers to use, abuse and dependence of the same substance (e.g. alcohol, opioid, cannabis, etc.), only one code should be assigned to identify the pattern of use based on the following hierarchy:

Chapter 5 - Guidelines

• If both use and abuse are documented, assign only the code for abuse

• If both abuse and dependence are documented, assign only the code for dependence

• If use, abuse and dependence are all documented, assign only the code for dependence

• If both use and dependence are documented, assign only the code for dependence.

Chapter 5 - Terminology

Use• 1. Take, hold, or deploy (something) as a means of

accomplishing a purpose or achieving a result; employ.• 2. describing an action or state of affairs that was done

repeatedly or existed for a period in the past…"this road used to be a dirt track"

Chapter 5 - Terminology

Abuse1. use (something) to bad effect or for a bad

purpose; misuse (verb)2. the improper use of something. (noun)

Chapter 5 - Terminology

DependenceThe state of relying on or being controlled by someone or something else. (noun)

Chapter 5: Mental, Behavioral and Neurodevelopmental disorders (F01 – F99)

From the DSM V –

The word addiction is not applied as a diagnostic term.

Clinical Criteria

Substance – Alcohol, Opioids, Cannabis, Sedatives, Cocaine, Other stimulant, Hallucinogen, Nicotine, Inhalants, Other psychoactive substance

Related disorders – i.e. delirium, anxiety Status – Abuse, Use, in remission

Chapter 5F20-F29 Schizophrenia, schizotypal, delusional, and other non-

mood psychotic disorders

Schizophrenia

The block that covers schizophrenia, schizotypal states and delusional disorders (F20-F29) has been expanded by the introduction of new categories such as:

• undifferentiated schizophrenia• postschizophrenic depression• schizotypal disorder.

Schizophrenia• It is relevant to this discussion that, given a set of affective

symptoms, the addition of only mood-incongruent delusions is not sufficient to change the diagnosis to a schizoaffective category.

• At least one typically schizophrenic symptom must be present with the affective symptoms during the same episode of the disorder.

• DSM provides further guidance

Schizophrenia - TypeF20.0 Paranoid schizophrenia F20.1 Disorganized schizophrenia F20.2 Catatonic schizophrenia F20.3 Undifferentiated schizophrenia F20.5 Residual schizophrenia F20.81 Schizophreniform disorder F20.89 Other schizophrenia F20.9 Schizophrenia, unspecified

Schizoaffective disorders - Type• F25.0 Schizoaffective disorder, bipolar type • F25.1 Schizoaffective disorder, depressive type • F25.8 Other schizoaffective disorders • F25.9 Schizoaffective disorder, unspecified

Chapter 5

• F30-F39 Mood [affective] disorders• Bipolar Disorder• Depression

• There have been some addition in this section for our 2017 updates.

• Documentation will need to keep up with the effort to have fewer unspecified codes.

Bipolar Disorder• Bipolar disorder, also known as manic-depressive illness, is a

brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks.

• Symptoms of bipolar disorder are severe. They are different from the normal ups and downs that everyone goes through from time to time.

• Bipolar disorder symptoms can result in damaged relationships, poor job or school performance, and even suicide. But bipolar disorder can be treated, and people with this illness can lead full and productive lives.

National Institute of Mental Health

Bipolar disorder

• Bipolar I Disorder—defined by manic or mixed episodes that last at least seven days, or by manic symptoms that are so severe that the person needs immediate hospital care. Usually, depressive episodes occur as well, typically lasting at least 2 weeks.

• Bipolar II Disorder—defined by a pattern of depressive episodes and hypomanic episodes, but no full-blown manic or mixed episodes.

Bipolar disorder• Bipolar Disorder Not Otherwise Specified (BP-NOS)—

diagnosed when symptoms of the illness exist but do not meet diagnostic criteria for either bipolar I or II. However, the symptoms are clearly out of the person's normal range of behavior.

• Cyclothymic Disorder, or Cyclothymia—a mild form of bipolar disorder. People with cyclothymia have episodes of hypomania as well as mild depression for at least 2 years. However, the symptoms do not meet the diagnostic requirements for any other type of bipolar disorder.

Bipolar disorder• F31.0 Bipolar disorder, current episode hypomanic • F31.10 Bipolar disorder, current episode manic without psychotic

features, unspecified • F31.11 Bipolar disorder, current episode manic without psychotic

features, mild • F31.12 Bipolar disorder, current episode manic without psychotic

features, moderate • F31.13 Bipolar disorder, current episode manic without psychotic

features, severe • F31.2 Bipolar disorder, current episode manic severe with psychotic

features

Bipolar disorder• F31.30 Bipolar disorder, current episode depressed, mild or

moderate severity, unspecified • F31.31 Bipolar disorder, current episode depressed, mild • F31.32 Bipolar disorder, current episode depressed, moderate • F31.4 Bipolar disorder, current episode depressed, severe,

without psychotic features • F31.5 Bipolar disorder, current episode depressed, severe, with

psychotic features

Bipolar disorder• F31.60 Bipolar disorder, current episode mixed, unspecified • F31.61 Bipolar disorder, current episode mixed, mild • F31.62 Bipolar disorder, current episode mixed, moderate • F31.63 Bipolar disorder, current episode mixed, severe, without

psychotic features • F31.64 Bipolar disorder, current episode mixed, severe, with

psychotic features

Bipolar disorder• F31.70 Bipolar disorder, currently in remission, most recent episode unspecified • F31.71 Bipolar disorder, in partial remission, most recent episode hypomanic • F31.72 Bipolar disorder, in full remission, most recent episode hypomanic • F31.73 Bipolar disorder, in partial remission, most recent episode manic • F31.74 Bipolar disorder, in full remission, most recent episode manic • F31.75 Bipolar disorder, in partial remission, most recent episode depressed • F31.76 Bipolar disorder, in full remission, most recent episode depressed • F31.77 Bipolar disorder, in partial remission, most recent episode mixed • F31.78 Bipolar disorder, in full remission, most recent episode mixed

Bipolar disorder• F31.81 Bipolar II disorder • F31.89 Other bipolar disorder • F31.9 Bipolar disorder, unspecified

Depression• Depressive illnesses are disorders of the brain. Brain-imaging

technologies, such as magnetic resonance imaging (MRI), have shown that the brains of people who have depression look different than those of people without depression.

• The parts of the brain involved in mood, thinking, sleep, appetite, and behavior appear different. But these images do not reveal why the depression has occurred. They also cannot be used to diagnose depression.

Depression

• Major depression,—severe symptoms that interfere with your ability to work, sleep, study, eat, and enjoy life. An episode can occur only once in a person’s lifetime, but more often, a person has several episodes.

Depression

• Persistent depressive disorder—depressed mood that lasts for at least 2 years. A person diagnosed with persistent depressive disorder may have episodes of major depression along with periods of less severe symptoms, but symptoms must last for 2 years.

Depression• Psychotic depression, which occurs when a person has severe

depression plus some form of psychosis, such as having disturbing false beliefs or a break with reality (delusions), or hearing or seeing upsetting things that others cannot hear or see (hallucinations).

• Postpartum depression, which is much more serious than the "baby blues" that many women experience after giving birth, when hormonal and physical changes and the new responsibility of caring for a newborn can be overwhelming. It is estimated that 10 to 15 percent of women experience postpartum depression after giving birth.

Depression, single episode• 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 • F32.3 Major depressive disorder, single episode, severe with

psychotic features

Depression, single episode• F32.4 Major depressive disorder, single episode, in partial

remission • F32.5 Major depressive disorder, single episode, in full remission • F32.8 Other depressive episodes • F32.9 Major depressive disorder, single episode, unspecified

Depression, recurrent• F33.0 Major depressive disorder, recurrent, mild • F33.1 Major depressive disorder, recurrent, moderate • F33.2 Major depressive disorder, recurrent severe without

psychotic features • F33.3 Major depressive disorder, recurrent, severe with psychotic

symptoms

Depression, recurrent• F33.40 Major depressive disorder, recurrent, in remission,

unspecified • F33.41 Major depressive disorder, recurrent, in partial remission • F33.42 Major depressive disorder, recurrent, in full remission • F33.8 Other recurrent depressive disorders • F33.9 Major depressive disorder, recurrent, unspecified

Mood disorders• F34.0 Cyclothymic disorder

• Affective personality disorder Cycloid personality CyclothymiaCyclothymic personality

• F34.1 Dysthymic disorder • Depressive neurosis Depressive personality disorder Dysthymia

Neurotic depressionPersistent anxiety depression

• Excludes2: anxiety depression (mild or not persistent) (F41.8) • F34.8 Other persistent mood [affective] disorders • F34.9 Persistent mood [affective] disorder, unspecified

Chapter 5F40-F48 Anxiety, dissociative, stress-related, somatoform and

other nonpsychotic mental disorders

Phobias• Phobias are emotional and physical reactions to feared objects or situations.

Symptoms of a phobia include the following:• Feelings of panic, dread, horror, or terror• Recognition that the fear goes beyond normal boundaries and the actual

threat of danger• Reactions that are automatic and uncontrollable, practically taking over the

person’s thoughts• Rapid heartbeat, shortness of breath, trembling, and an overwhelming desire

to flee the situation—all the physical reactions associated with extreme fear• Extreme measures taken to avoid the feared object or situation

Psychiatry.org

Phobias• F40.00 Agoraphobia, unspecified • F40.01 Agoraphobia with panic disorder • F40.02 Agoraphobia without panic disorder • F40.10 Social phobia, unspecified • F40.11 Social phobia, generalized • F40.9 Phobic anxiety disorder, unspecified

Phobias• F40.210 Arachnophobia • F40.218 Other animal type phobia • F40.220 Fear of thunderstorms • F40.228 Other natural environment type phobia • F40.230 Fear of blood • F40.231 Fear of injections and transfusions • F40.232 Fear of other medical care • F40.233 Fear of injury

Phobias• F40.240 Claustrophobia • F40.241 Acrophobia • F40.242 Fear of bridges • F40.243 Fear of flying • F40.248 Other situational type phobia • F40.290 Androphobia• F40.291 Gynephobia• F40.298 Other specified phobia

AnxietyAnxiety disorders are the most common of emotional disorders and affect more than 25 million Americans. Many forms and symptoms may include:

• Overwhelming feelings of panic and fear• Uncontrollable obsessive thoughts• Painful, intrusive memories• Recurring nightmares• Physical symptoms such as feeling sick to your stomach, “butterflies” in your stomach, heart pounding, startling easily, and muscle tension

Panic attacks• The core symptom of panic disorder is the panic attack, an overwhelming

combination of physical and psychological distress. During an attack several of these symptoms occur in combination:

• Pounding heart or chest pain• Sweating, trembling, shaking• Shortness of breath, sensation of choking• Nausea or abdominal pain• Dizziness or lightheadedness• Feeling unreal or disconnected• Fear of losing control, “going crazy,” or dying• Numbness• Chills or hot flashes

• Because symptoms are so severe, many people with panic disorder believe they are having a heart attack or other life-threatening illness.

Anxiety disorders• F41.0 Panic disorder [episodic paroxysmal anxiety] without

agoraphobia • F41.1 Generalized anxiety disorder • F41.3 Other mixed anxiety disorders • F41.8 Other specified anxiety disorders • F41.9 Anxiety disorder, unspecified • F42 Obsessive-compulsive disorder

Adjustment disorders• F43.0 Acute stress reaction • F43.10 Post-traumatic stress disorder, unspecified • F43.11 Post-traumatic stress disorder, acute • F43.12 Post-traumatic stress disorder, chronic • F43.8 Other reactions to severe stress • F43.9 Reaction to severe stress, unspecified

Adjustment disorders• F43.20 Adjustment disorder, unspecified • F43.21 Adjustment disorder with depressed mood • F43.22 Adjustment disorder with anxiety • F43.23 Adjustment disorder with mixed anxiety and

depressed mood • F43.24 Adjustment disorder with disturbance of conduct • F43.25 Adjustment disorder with mixed disturbance of

emotions and conduct • F43.29 Adjustment disorder with other symptoms

Somatoform disorders• People with somatoform disorders are not faking their

symptoms. The pain and other problems they experience are real. The symptoms can significantly affect daily functioning.

• Somatoform disorders are mental illnesses that cause bodily symptoms, including pain. The symptoms can't be traced back to any physical cause. And they are not the result of substance abuse or another mental illness

Webmd.com

Somatoform disorders

• F45.0 Somatization disorder • F45.1 Undifferentiated somatoform disorder • F45.20 Hypochondriacal disorder, unspecified • F45.21 Hypochondriasis • F45.22 Body dysmorphic disorder • F45.29 Other hypochondriacal disorders

Somatoform disorders

• F45.41 Pain disorder exclusively related to psychological factors

• F45.42 Pain disorder with related psychological factors• F45.8 Other somatoform disorders • F45.9 Somatoform disorder, unspecified

Chapter 5F50-F59 Behavioral syndromes associated with physiological

disturbances and physical factors

Behavior syndromes

• F50 Eating disorders • F51 Sleep disorders not due to a substance or known

physiological condition • F52 Sexual dysfunction not due to a substance or known

physiological condition • F53 Puerperal psychosis

• Postpartum depression

F55 Abuse of non-psychoactive substances

• Excludes2: abuse of psychoactive substances (F10-F19) • F55.0 Abuse of antacids • F55.1 Abuse of herbal or folk remedies • F55.2 Abuse of laxatives • F55.3 Abuse of steroids or hormones • F55.4 Abuse of vitamins • F55.8 Abuse of other non-psychoactive substances

Chapter 5F60-F69 Disorders of adult personality and behavior

Specific Personality disorders• F60.0 Paranoid personality disorder • F60.1 Schizoid personality disorder • F60.2 Antisocial personality disorder • F60.3 Borderline personality disorder • F60.4 Histrionic personality disorder • F60.5 Obsessive-compulsive personality disorder • F60.6 Avoidant personality disorder • F60.7 Dependent personality disorder • F60.81 Narcissistic personality disorder • F60.89 Other specific personality disorders

Impulse disorders• F63.0 Pathological gambling • F63.1 Pyromania • F63.2 Kleptomania • F63.3 Trichotillomania

• Hair plucking• F63.81 Intermittent explosive disorder • F63.89 Other impulse disorders • F63.9 Impulse disorder, unspecified

Other adult personality and behavior disorders • F64 Gender identity disorders • F65 Paraphilias • F66 Other sexual disorders • F68 Other disorders of adult personality and behavior • F69 Unspecified disorder of adult personality and

behavior

Chapter 5Intellectual Disabilities (F70-F79)

Intellectual Disabilities

• F70 Mild intellectual disabilities • IQ level 50-55 to approximately 70 Mild mental

subnormality• F71 Moderate intellectual disabilities • IQ level 35-40 to 50-55 Moderate mental subnormality• F72 Severe intellectual disabilities • IQ 20-25 to 35-40

Severe mental subnormality

Intellectual Disabilities

• F73 Profound intellectual disabilities • IQ level below 20-25 Profound mental subnormality• F78 Other intellectual disabilities • F79 Unspecified intellectual disabilities • Mental deficiency NOS Mental subnormality NOS

Chapter 5Pervasive and specific developmental disorders (F80-F89)

Specific developmental disorders of speech and language • F80.0 Phonological disorder • F80.1 Expressive language disorder • F80.2 Mixed receptive-expressive language disorder • F80.4 Speech and language development delay due to hearing

loss • F80.81 Childhood onset fluency disorder

• Cluttering NOS Stuttering NOS • F80.9 Developmental disorder of speech and language,

unspecified

F81 Specific developmental disorders of scholastic skills

• F81.0 Specific reading disorder • Backward reading'

• 81.2 Mathematics disorder • F81.81 Disorder of written expression

• Specific spelling disorder • F81.89 Other developmental disorders of scholastic skills • F81.9 Developmental disorder of scholastic skills,

unspecified

Coordination Disorder

• F82 Specific developmental disorder of motor function • Clumsy child syndrome • Developmental coordination disorder • Developmental dyspraxia

F84 Pervasive developmental disorders

• F84.0 Autistic disorder • Infantile autism, Infantile psychosis, Kanner's syndrome

• F84.2 Rett's syndrome • F84.5 Asperger's syndrome • F84.8 Other pervasive developmental disorders • F84.9 Pervasive developmental disorder, unspecified

Chapter 5

• F88 Other disorders of psychological development • Developmental agnosia

• F89 Unspecified disorder of psychological development • Developmental disorder NOS

Chapter 5Behavioral and emotional disorders with onset usually

occurring in childhood and adolescence (F90-F98)

Attention deficit disorder

• Attention deficit hyperactivity disorder (ADHD) is a condition in which a person has trouble paying attention and focusing on tasks, tends to act without thinking, and has trouble sitting still. It may begin in early childhood and can continue into adulthood.

• Without treatment, ADHD can cause problems at home, at school, at work, and with relationships. In the past, ADHD was called attention deficit disorder (ADD).

Attention-deficit hyperactivity disorders• F90.0 Attention-deficit hyperactivity disorder,

predominantly inattentive type • F90.1 Attention-deficit hyperactivity disorder,

predominantly hyperactive type • F90.2 Attention-deficit hyperactivity disorder, combined

type • F90.8 Attention-deficit hyperactivity disorder, other type • F90.9 Attention-deficit hyperactivity disorder, unspecified

type

Conduct disorder

• F91.0 Conduct disorder confined to family context • F91.1 Conduct disorder, childhood-onset type • F91.2 Conduct disorder, adolescent-onset type • F91.3 Oppositional defiant disorder • F91.8 Other conduct disorders • F91.9 Conduct disorder, unspecified

Emotional disorder

• F93.0 Separation anxiety disorder of childhood • F93.8 Other childhood emotional disorders

• Identity disorder• F93.9 Childhood emotional disorder, unspecified

Behavior and Emotional Disorders

• F94 Disorders of social functioning with onset specific to childhood and adolescence

• F95 Tic disorder • F98 Other behavioral and emotional disorders with

onset usually occurring in childhood and adolescence

• F99 Mental disorder, not otherwise specified

Psychology

CPT Coding

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• The Psychiatry subsection can be found in the Medicine Section. The code range is 90785 through 90899.

• The guidelines are extensive and must be read prior to coding.

• Take note of the many add-on codes.

Procedural Coding

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• Place of Service

• Time

• Prolonged Care

Psychiatry (90785-90899)

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• Add on code 90785

The parenthetical notes provide information about which codes are used with this one.

The guidelines provide information about what would be needed in the documentation to support the use.

Psychiatry – Interactive Complexity

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• 90791 – 90792

• Consultation service

• Medical Services

Psychiatry – Diagnostic Procedures

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• Time based• Add-on codes

• 90833, 90836, 90838• E/M or not? – Medical Management

Psychiatry - Psychotherapy

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• 90839, 90840• Add-on code• Time based – face to face

• Does not have to be continuous• Guidelines provide explanation and instructions

Psychiatry - Crisis

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• Psychoanalysis• Family• Group• Pharmacologic management (add on code)• Hypnotherapy

Psychiatry – Other services

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Case Studies

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• Individual Psychotherapy: x. Total Time spent: 45 minutes.

• Subjective report/Symptoms/Psychosocial Stressors: Patient reported that the new acceptance and intentional redirection approach to obsessions and refraining from mental compulsions has been working and he has had significantly fewer obsessional thoughts and has been able to accept his anxiety and let it just be.

Example 1

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• OBJECTIVE: Mental Status Orientation: Any changes from last visit? no Time: y Place: y Person: y Situation: y Appearance: normal Behavior : normal Speech: normal, very talkative Mood: neutral Affect: neutral Thought Content: normal

• Active Problems (2) GENERALIZED ANXIETY DISORDER Obsessive compulsive disorder

Example 1

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• ASSESSMENT : Objective Report/Progress/Prognosis: Patient is showing improvement in this last obsession he has been experiencing and since we have determined that he was over-using the cognitive skills as compulsions, his new acceptance approach has been significantly reducing symptoms. Still, patient has tendency to try to analyze his symptoms and progress,

Example 1

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TREATMENT PLAN: • CBT: x • Clinical Therapeutic Procedures and Techniques:

Went over homework and progress, discussed maintenance. Patient will come in for one more 30 min session to see if he has maintained improvement in symptoms.

Example 1

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• CPT Code • 90834 – Psychotherapy , 45 minutes with patient and/or family

member

• This note describes just therapy. There was an exam and there was a documented history. The intent of the encounter was to review methods for the patient to use to make positive changes in a behavior. There were no medications to be reviewed or prescribed, therefore there was no need for an evaluation and management code to be used.

Example 1 – CPT Code

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• Generalized Anxiety Disorder – Begin in the index and look up the main term Disorder. Then follow to the subterm anxiety and then to the indented term generalized. The referenced code is F41.1 This can be confirmed in the tabular in Chapter 5.

• Obsessive compulsive disorder - Begin in the index and look up the main term Disorder. The subterm obsessive compulsive is listed alphabetically below the main term. The code referenced is F42 and it can be confirmed in the tabular in Chapter 5.

Example 1 – ICD-10-CM

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Session Length: 15 minutesProvider: MDPatient: Age: 28 Sex: FemaleMEDICATION MANAGEMENT FOLLOW UP VISITCHIEF COMPLAINT: anxiety

IDENTIFICATION:28-year-old female with Major Depressive Disorder, Generalized Anxiety Disorder, and ADHD, by History.

Example 2

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INTERIM HISTORY:Since her last appointment, her anxiety level has been higher under increased family stress. Several members of her in-law family are currently staying with them, and it has been a stress on everyone. Her mood has been "stressed." She has felt more irritable. She has been struggling with insomnia with the increased stress. Although feeling frustrated and stressed, she denies any worsening depression. She continues to function well at work and at home. Her attention and concentration have been fine. We discussed risks, benefits, and alternative medications for insomnia. We will start trazodone 25-100 mg nightly as needed for sleep.

Example 2

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ALLERGIES: Sulfa.MEDICATIONS:Zoloft 100 mg daily.Wellbutrin XL 450 mg daily.OCP, Prenatal vitamins.PAST MEDICATIONS:Adderall 20 mg TID was effective for ADHD in the past. Ritalin.Klonopin. Ativan for airline travel anxiety.PAST MEDICAL HISTORY:Migraines.

Example 2

102

MENTAL STATUS EXAM:Appearance: Well nourished, well groomed, young, white female, appropriate appearingAttitude: Pleasant and cooperativeBehavior: No psychomotor agitation or retardationSpeech: Normal rate, rhythm, volume, and toneMood: "stressed"Affect: Somewhat anxious appearing, but overall euthymicThought process: Linear, logical, and goal-orientedThought content: No suicidal or homicidal ideation; no delusions apparent

Example 2

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Perception: No auditory or visual hallucinations; does not appear to be responding to internal stimuliInsight: GoodJudgment: GoodImpulse Control: GoodOrientation: Oriented to person, place, time, and purpose

Example 2

104

DIAGNOSES:Generalized Anxiety Disorder.Major Depressive Disorder, Single Episode, ModerateADHD, Inattentive Type, by HistoryPLAN:1. Continue Zoloft 100 mg daily for depression and anxiety.2. Continue Wellbutrin XL 450 mg daily for mood, energy, motivation, and focus.3. Start trazodone 25-100 mg nightly as needed for sleep.4. Follow up in three months, or sooner as needed

Example 2

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This patient presented to have a medication follow up with her therapist. There is a status obtained and a exam performed. Medication is prescribed. There is no therapy performed during this encounter. The CPT code will be an E/M code based on the level of history, exam and MDM documented. The level of service would be a 99214.

HX = Detailed Exam = Detailed MDM = Moderate, chronic conditions with one not improving and

prescriptions.

Example 2 -CPT Coding

106

Generalized Anxiety Disorder - Begin in the index and look up the main term Disorder. Then follow to the subterm anxiety and then to the indented term generalized. The referenced code is F41.1 This can be confirmed in the tabular in Chapter 5.Major Depressive Disorder, Single Episode, Moderate - In the index look up the main term Disorder. Next look for the subterm depression. Follow the indented terms to major/single episode/moderate. Code F32.1 will be referenced and can be confirmed in the tabular in Chapter 5.ADHD, Inattentive Type – In the index look up the main term disorder. Follow alphabetically to the subterm attention deficit hyperactivity, then follow to the indented term inattentive type. This will reference code F90.0 - this can be confirmed in the tabular in Chapter 5.

Example 2 – ICD10 Coding

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• The insomnia is a symptom of the anxiety and does not need to be separately coded

Example 2 – ICD10 Coding

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Resources

• The ICD-10 Classification of Mental and Behavioral Disorders

• Clinical descriptions and diagnostic guidelines • World Health Organization • DSM-V

Thank you!

Annie BoyntonBS, RHIT, CPCO, CPC, CCS, COC, CCS-P, CPC-P, CPC-I

boyntonhms@gmail.com

Questions?

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ATL711CEU

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