Pediatric Coding Alert

Question: Our provider used the words “personal history of oppositional defiant disorder [ODD]” in a patient record. When I queried her about this, she said that the patient had personally reported the condition. My question is, how do I report this? Do I use F91.3 or Z86.59?

Alabama Subscriber

Answer: In this particular situation, you cannot use either of the codes. In order to record a diagnosis of F91.3 (Oppositional defiant disorder), you will need documentation that the patient has an active ODD diagnosis. And in order to record Z86.59 (Personal history of other mental and behavioral disorders), you will need documentation that the patient had the condition, but the diagnosis is no longer current.

In this situation, there is no evidence that either status is true for this patient, and you cannot take a patient’s self-diagnosis as proof of a diagnosis. Simply put, as the old coding saying goes, if it is not documented, it did not happen. So, unless your provider includes documentation to support either code, you would leave this condition uncoded.