Psychiatry Coding & Reimbursement Alert

Hint: Don’t code diagnosis of adjustment disorder under F43.1.

When you begin using ICD-10 codes after Oct.1, 2014, your psychiatrist’s post-traumatic stress disorder (PTSD) diagnoses will require specifics on disease status for accurate code assignment.

ICD-9: You’ll use 309.81 (Posttraumatic stress disorder) to report a PTSD diagnosis regardless of whether the symptoms are acute or chronic.

However, you cannot report 309.81 if the diagnosis is acute stress disorder (308.3), or post traumatic brain syndrome (nonpsychotic, 310.2 or psychotic, 293.0-293.9).

Look For Status in ICD-10

ICD-9 code 309.81 crosswalks to F43.1_ (Post-traumatic stress disorder) in ICD-10. F43.1 expands to include PTSD status description in the 5^thcharacter in these three codes:

F43.10 – Post-traumatic stress disorder, unspecified

F43.11 – Post-traumatic stress disorder, acute

F43.12 – Post-traumatic stress disorder, chronic

"In essence, ICD-10 is dividing one code into three," observes Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. "ICD-10 will permit you to clearly delineate whether the PTSD is acute or chronic, if known, which is not something that you can do under ICD-9," adds Moore.

So you will now have to look more specifically into the documentation to check whether or not your psychiatrist has identified if the condition is acute or chronic. If the status of the condition is identified, you will need to report it with F43.11 or F43.12; otherwise,you will use F43.10. But prior to using F43.10, it is best to query your clinician to see if you can report the condition more specifically.

Focus on These Basics Briefly

Your psychiatrist will arrive at a diagnosis of post-traumatic stress disorder based on a complete history and an evaluation of the person’s signs and symptoms. Your psychiatrist will perform a complete mental status examination, a complete psychiatric and medical history of the patient and family, a review of systems, and ordering and interpreting diagnostic tests.

Your psychiatrist will note observations based on criteria specified by Diagnostic and Statistical Manual of Mental Disorders (DSM) in the patient documentation. The most important criterion that will point your psychiatrist towards PTSD will involve the patient experiencing or witnessing a traumatic event (maybe in the form of injury, abuse or death). Your psychiatrist makes observations that point to the person reliving this traumatic experience in the form of flashbacks, dreams or intense thoughts and distress.

Look for these details:In the patient notes, your psychiatrist will note that the patient might avoid situations and persons that will make them remember the traumatic experience or might have incomplete recollections about some parts of the experience. Your psychiatrist might observe that the patient has sleep difficulties, irritability of mood, and troubles with focus.

During a physical examination, your psychiatrist might note poor personal hygiene and agitated appearance with poor sense of orientation to time or place. You might also see some other co-existing conditions such as depression or anxiety and tendency towards suicide or even homicide.

The arrival of the diagnosis is made by your psychiatrist mainly by observations and through history, although some laboratory tests such as epinephrine and norepinephrine levels, cortisol levels, and levels of natural opiates might also help support the diagnosis.

The care planning will include medical management with serotonin selective reuptake inhibitors and other medications. Your psychiatrist will also use cognitive behavioral therapy, hypnotic therapy and relaxation techniques to help the patient overcome the traumatic experience and its effects.

Example: Your psychiatrist evaluates a 45-year-old male patient who has been referred by his primary care physician. The referring physician suspects the patient is suffering from post-traumatic stress disorder following a fire fighting incident six months prior. The patient was a fire fighter, and the incident caused the death of two of his colleagues and six other people, including two children.

The person is accompanied by his wife who says that he relives the incident on a day-to-day basis and has nightmares that affect his sleep to such an extent that he has trouble falling asleep and becomes extremely irritable. The incident has left him mentally scarred to such an extent that he is now on indefinite leave and avoids meeting up with any of his colleagues.

Based on observations made from physical examination and history, our psychiatrist arrives at a diagnosis of PTSD (acute). He puts the patient on sertraline and plans behavioral psychotherapy along with hypnosis and review of medication at a later date.

What to Report: You will report the initial diagnostic evaluation that the psychiatrist provided with 90792 (Psychiatric diagnostic evaluation with medical services) and the diagnosis with 309.81 if you’re using ICD-9 codes. You will report the diagnosis with F43.11 if you are using ICD-10 code sets since the patient is currently experiencing acute symptoms of PTSD that need immediate attention.