Primary Care Coding Alert

Question: When a patient exhibits signs of depression, but the FP does not diagnose depression, which ICD-9 codes should I use? The FP recently treated a new patient whose father just died. During the course of a level-two E/M, the physician discovered that the patient had insomnia and was not eating much. However, the physician did not note depressive disorder in the documentation.

Missouri Subscriber

Answer: Without a definitive diagnosis from the doctor, you will want the diagnosis coding to reflect the patient's signs and symptoms.

On your claim, report 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: an expanded problem-focused history; an expanded problem-focused examination; straightforward medical decision-making ) for the E/M.

Remember to attach 307.42 (Persistent disorder of initiating or maintaining sleep) to 99202 to represent the patient's insomnia and 783.0 (Anorexia) to 99202 to represent the patient's appetite loss.