Neurology & Pain Management Coding Alert

Question: The provider treated a new patient who suffered from hallucinations. Notes indicate that the provider performed a level-three office evaluation and management (E/M) service. What is the best ICD-10 code for this condition?

Minnesota Subscriber

Answer: For the proper diagnosis on your 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity …) claim, you’ll need to check with the provider to get some more information.

Why? The hallucinations diagnoses are broken down thusly in ICD-10:

• R44.0 (Auditory hallucinations)
• R44.1 (Visual hallucinations)
• R44.2 (Other hallucinations)
• R44.3 (Hallucinations, unspecified)

If the provider isn’t able to give you any more about the specifics of the hallucinations, R44.3 is likely your best bet.

Excludes alerts: While most of your hallucinations diagnoses will be from this short list, be sure to check out the Excludes1 and Excludes2 notes under the lead code for this diagnosis family: R44.- (Other symptoms and signs involving general sensations and perceptions). It contains vital info on when not to choose one of the above codes for your hallucinations diagnosis.