Primary Care Coding Alert

Don’t let similar-sounding Dx cloud your reporting.

Diagnosis coding for anxiety disorders can produce … well … anxiety in a coder, too. After all, there are a lot of confusing diagnoses, such as “anxiety depression,” that can make pinning down the most specific code extremely difficult.

And if your provider notes signs and symptoms that may not be associated with the condition, they can have profound effect on your code choices, too.

To try and take the mystery out of coding for anxiety disorders, our experts analyzed this case study to help you zero in on the right codes whenever a similar encounter crosses your desk.

Case Study

A 54-year-old woman presents to your provider complaining of difficulty sleeping, nervousness, gastrointestinal (GI) problems, rapid breathing, mild depression, and heart palpitations. Your provider administers a Patient Health Questionnaire for Depression and Anxiety (PHQ-9) and a Generalized Anxiety Disorder Test (GAD-7) to determine the patient’s condition. After scoring the test, your provider offers a diagnosis of anxiety with depression.

Become Familiar With Anxiety-Associated Signs and Symptoms

You know that per ICD-10 guideline B.6, “signs and symptoms that may not be associated routinely with a disease process should be coded when present.” Consequently, “since the provider has made a definitive determination of what the patient’s problem is, you code only the diagnosis and not the symptoms,” says Melanie Witt, RN, CPC, MA, an independent coding expert based in Guadalupita, New Mexico.

“However, as one of the symptoms is GI problems, the provider may well perform additional lab tests to rule out a physical problem. You could also report that diagnosis, assuming a physical problem was found, and link it to any lab or diagnostic tests performed,” Witt adds.

In that case, you would report the appropriate ICD-10 code for the identified GI problem or K92.9 (Disease of digestive system, unspecified) if a more specific diagnosis was not available, depending on the results of any tests your provider ordered. But you would not report any of the other signs and symptoms reported in your provider’s notes, as they are all common to the diagnosis of anxiety with depression.

Multiple Tests, Multiple Units?

You would then document use of both the GAD-7 and PHQ-9 with 96127 (Brief emotional/behavioral assessment (eg, depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument). However, you will need to know your payer’s guidelines when assembling the claim, as the two tests can be reported in two different ways.

As the descriptor states that you can report the code “per standardized instrument,” some payers may just require you to report units of 96127. But you could also report one unit of 96127 and a second unit with modifier 59 (Distinct procedural service) appended if a payer prefers this way of reporting. You’ll also report the appropriate level of evaluation and management (E/M) service for the encounter from 99201-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …).

Find Definitive Dx in This Code’s Notes ...

The most difficult part of this case study is assigning the specific diagnosis code for anxiety with depression. “This one can be a little tricky as the level of depression will play a role in determining the diagnosis,” says Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, billing/credentialing/auditing/coding coordinator at County of Stanislaus Health Services Agency in Modesto, California. “If the depression is mild or not persistent, then you would select F41.8 [Other specified anxiety disorders],” Johnson continues. “The code includes mixed anxiety and depressive disorder,” adds Witt, as it lists two similar-sounding synonyms: “Mixed anxiety and depressive disorder” and “Anxiety depression (mild or not persistent).”

However, “if the determination is that the patient has a major depressive disorder, then you would look at F32.- [Major depressive disorder, single episode], if the episode is single,” Johnson elaborates. “You would only code this if there has been no previous major depressive episode, and you would then list the anxiety separately under F41.- [Other anxiety disorders], excluding F41.8 as the depression is not determined to be mild,” Johnson reasons. And if the patient has a major depressive disorder that’s recurrent, you should look to F33.- (Major depressive disorder, recurrent).

... But Ignore This Persistent Condition

The synonyms to F41.8 look almost identical to one of those that accompany F34.1 (Dysthymic disorder): “Persistent anxiety depression.” But “coders should not jump the gun and assume a more persistent or serious anxiety/depressive state without more information from the provider,” Witt clarifies. “F34.1 includes persistent anxiety depression, but this is a very different condition than the one described above, as the presenting symptoms do not usually include heart palpitations and GI symptoms. Rather, they are related more to sadness and feelings of hopelessness that last over many years and come and go,” Witt adds.