Psychiatry Coding & Reimbursement Alert

Hint: Distinguish from anorexia nervosa of binge eating or purging type to nail the diagnosis.

When your clinician diagnoses bulimia nervosa, you’ll be relieved to know that there is not much variation in the way you’ll report this diagnosis using ICD-10 codes except for a few changes to the list of inclusions and exclusions currently in use with the ICD-9 system of codes.

ICD-9: You’ll use 307.51 (Bulimia nervosa) to report a diagnosis of bulimia nervosa. You will use the same diagnosis code if your clinician mentions the diagnosis as overeating of nonorganic origin. However, you cannot report 307.51 if the diagnosis is anorexia nervosa (307.1), anorexia of unspecified cause (783.0), overeating of unspecified cause (783.6), vomiting NOS (787.03), cyclical vomiting (536.2), cyclical vomiting associated with migraine (346.2x) or psychogenic cyclical vomiting (306.4).

ICD-10: When you begin using ICD-10 codes, a bulimia nervosa diagnosis will crosswalk from 307.51 to F50.2 (Bulimia nervosa). You will also report F50.2 if your clinician makes a diagnosis of bulimia NOS or hyperorexia nervosa.

However, you cannot report F50.2 if your clinician makes a diagnosis of anorexia nervosa of binge eating or purging type. This is reported using the ICD-10 code F50.02.

Focus on These Basics Briefly

Documentation spotlight: Your psychiatrist will arrive at a diagnosis of bulimia nervosa based on a complete history and an evaluation of the person’s signs and symptoms; the encounter will include a complete mental status examination, a complete psychiatric and medical history of the patient and family, and a review of systems, along with ordering and interpreting diagnostic tests.

Some of the symptoms that your clinician might note in the documentation will include lightheadedness, dizziness, palpitations, soreness of throat (due to purging), abdominal pain, bloating, dysphagia, flatulence, constipation, and amenorrhea.

Upon examination of the patient, your psychiatrist might note dry skin, nail damage, hair loss, edema, obesity, enlargement of parotids, hypotension, bradycardia, or tachycardia. Some of the lab tests that your clinician is likely to order if he suspects bulimia nervosa will include a CBC, amylase levels, blood chemistry to check for metabolic disturbances, and urinalysis to check hydration and to look for substance abuse.

If your clinician suspects bulimia nervosa, he might also ask for an ECG to rule out cardiovascular complications and order a DEXA scan to rule out osteoporosis. Your psychiatrist will also assess the patient for other co-morbidities such as anxiety, depression, impulse disorders, and ADHD. Your clinician would also check for suicidal tendencies, as many patients with bulimia nervosa have suicidal ideations and attempt suicide.

Your psychiatrist may also ask the patient to fill out assessment questionnaires, such as the SCOFF mnemonic questionnaire, eating disorder for primary care (ESP) questionnaire, and the eating attitude test (EAT) to help arrive at a diagnosis of bulimia nervosa.

The care planning will include medical management with serotonin selective reuptake inhibitors and other medications. Your psychiatrist will also use cognitive behavioral therapy, interpersonal psychotherapy, dynamic psychotherapy, family therapy, and nutritional rehabilitation counseling to help the patient overcome the eating disorder and the purging behavior.

Example: A psychiatrist was called to assess a 20-year-old female patient who was admitted to the emergency department of the hospital after her mother overheard her speaking on the phone with a friend about the suicidal thoughts that she had been having over the past few days.

The ED physician stabilized her and, upon seeing signs of depression and a possible eating disorder, decided to call in our psychiatrist to assess her. Her mother, who accompanied her, told the psychiatrist that she had been always a bright kid but had begun to feel insecure and developed insecure feelings about herself once her sister, who is seven years older,  began a successful career in modeling.

Her mother complained to our psychiatrist that she had often seen her daughter binge eat on ice-creams and chocolates. She suspected that her daughter would then use the bathroom to vomit out all that she had consumed, and the mother had often questioned her regarding this but was always given an evasive answer. She also stated that her daughter would over-exercise and would complain that she was becoming out of shape although she was quite thin.

Upon examination, our psychiatrist notes that the patient has severe dental damage and enlargement of the parotids, bilaterally. He also noticed sore spots on the patient’s pharynx due to the constant purging activity in which the patient engaged. Our psychiatrist also notes abdominal tenderness, edema, and tachycardia.

Suspecting bulimia, our psychiatrist ordered a chemistry panel, CBC, urinalysis, and tests for amylase levels. He also ordered an ECG to check for cardiovascular complications but found no abnormalities. The DEXA scan that he ordered to check her bone densities did not show any abnormalities.

Our psychiatrist also employed the SCOFF, ESP and the EAT questionnaires to confirm the diagnosis of bulimia nervosa.

Our psychiatrist counseled the patient to help alleviate her suicidal thoughts and prescribed sertraline for the patient to help reduce the symptoms of depression. He also planned psychodynamic psychotherapy and cognitive behavioral psychotherapy at a later date.

Our psychiatrist spent a total of 100 minutes in providing services to the patient, which included recording history, physical and mental status examination, review of lab test results, and administration of the questionnaires to the patient.

What to report: Since your psychiatrist was involved in crisis management of the suicidal tendency, you will report the services provided by your psychiatrist using the psychotherapy for crisis codes 90839 (Psychotherapy for crisis; first 60 minutes) for the first hour of services provided and +90840 (Psychotherapy for crisis; each additional 30 minutes [List separately in addition to code for primary service]) for services provided beyond the first hour.

You will report the diagnosis of bulimia nervosa with F50.2 if you are using the ICD-10 codes and 307.51 if you’re using ICD-9 codes.