Coding for Psychology - PDF Free Download

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 2

Key Terms 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 3

Psychiatry - What is it? 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. 4

Psychology - What is it? 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. 5

Psychosis - What is it? 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 6

Diagnoses 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) 7

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 5 F01-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 5 F10-F19 Mental and behavioral disorders due to psychoactive substance use

Chapter 5 C. 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 Abuse 1. use (something) to bad effect or for a bad purpose; misuse (verb) 2. the improper use of something. (noun)

Chapter 5 - Terminology Dependence The 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 5 F20-F29 Schizophrenia, schizotypal, delusional, and other nonmood 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 - Type F20.0 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 Cyclothymia Cyclothymic personality F34.1 Dysthymic disorder Depressive neurosis Depressive personality disorder Dysthymia Neurotic depression Persistent 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 5 F40-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

Anxiety Anxiety 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 5 F50-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 5 F60-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 5 Intellectual 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 5 Pervasive 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 5 Behavioral 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 85

Procedural Coding 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. 86

Psychiatry (90785-90899) Place of Service Time Prolonged Care 87

Psychiatry Interactive Complexity 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. 88

Psychiatry Diagnostic Procedures 90791 90792 Consultation service Medical Services 89

Psychiatry - Psychotherapy Time based Add-on codes 90833, 90836, 90838 E/M or not? Medical Management 90

Psychiatry - Crisis 90839, 90840 Add-on code Time based face to face Does not have to be continuous Guidelines provide explanation and instructions 91

Psychiatry Other services Psychoanalysis Family Group Pharmacologic management (add on code) Hypnotherapy 92

Case Studies 93

Example 1 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. 94

Example 1 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 95

Example 1 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, 96

Example 1 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. 97

Example 1 CPT Code 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. 98

Example 1 ICD-10-CM 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. 99

Example 2 Session Length: 15 minutes Provider: MD Patient: Age: 28 Sex: Female MEDICATION MANAGEMENT FOLLOW UP VISIT CHIEF COMPLAINT: anxiety IDENTIFICATION: 28-year-old female with Major Depressive Disorder, Generalized Anxiety Disorder, and ADHD, by History. 100

Example 2 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. 101

Example 2 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. 102

Example 2 MENTAL STATUS EXAM: Appearance: Well nourished, well groomed, young, white female, appropriate appearing Attitude: Pleasant and cooperative Behavior: No psychomotor agitation or retardation Speech: Normal rate, rhythm, volume, and tone Mood: "stressed" Affect: Somewhat anxious appearing, but overall euthymic Thought process: Linear, logical, and goal-oriented Thought content: No suicidal or homicidal ideation; no delusions apparent 103

Example 2 Perception: No auditory or visual hallucinations; does not appear to be responding to internal stimuli Insight: Good Judgment: Good Impulse Control: Good Orientation: Oriented to person, place, time, and purpose 104

Example 2 DIAGNOSES: Generalized Anxiety Disorder. Major Depressive Disorder, Single Episode, Moderate ADHD, Inattentive Type, by History PLAN: 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 105

Example 2 -CPT Coding 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. 106

Example 2 ICD10 Coding 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. 107

Example 2 ICD10 Coding The insomnia is a symptom of the anxiety and does not need to be separately coded 108

Resources The ICD-10 Classification of Mental and Behavioral Disorders Clinical descriptions and diagnostic guidelines World Health Organization DSM-V

Questions? Thank you! Annie Boynton BS, RHIT, CPCO, CPC, CCS, COC, CCS-P, CPC-P, CPC-I boyntonhms@gmail.com 110

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