Psychiatry Coding & Reimbursement Alert

Hint: Fugue in epilepsy is captured with a different code.

As we are slowly nearing the time for ICD-10 transition, you’ll need to gear up on your knowhow of these codes – but when it comes to your clinician diagnosing dissociative fugue, you can rest easy as it is more of a straight forward transition with no significant changes from the way you report the condition using ICD-9 system.

ICD-9: You’ll use 300.13 (Dissociative fugue) for dissociative fugue and hysterical fugue. However, you cannot report 300.13 if the diagnosis is adjustment reaction (309.0-309.9); gross stress reaction (308.0-308.9); hysterical personality (301.50-301.59); or psychophysiological disorders (306.0-306.9).

ICD-10: When you begin using ICD-10 codes a diagnosis of dissociative fugue, that you will report using ICD-9 code 300.13 will crosswalk to F44.1 (Dissociative fugue). You cannot report F44.1 if your clinician makes a diagnosis of post-ictal fugue in epilepsy. These are captured using G40.-.

Pay Heed to These Basics Briefly

Documentation spotlight: Your psychiatrist will arrive at a diagnosis of dissociative fugue 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 along with ordering and interpreting diagnostic tests.

Some of the signs and symptoms that make your clinician suspect dissociative fugue will include unexplained, sudden travel away from the person’s home or workplace. The patient will often be not able to recall these episodes of absence or might have trouble recollecting some events of the past. They also seem to suffer from an identity crisis and will usually assume a different identity during the episodes of fugue.

Upon examination, your psychiatrist might note that the patient is alert and oriented to self and will have very poor reasoning abilities. The patient will have poor abilities to maintain eye contact while thought process might be varied. Your clinician might note violent ideation but the patient will not usually have any suicidal tendencies.

Your clinician might opt for some tests such as MRI, CT scan and electroencephalogram to diagnose the condition mainly by ruling out other conditions that might produce similar symptoms.

Example: Your psychiatrist was called to assess a 33-year-old male patient who was admitted to the emergency department of the hospital after he was found by the police wandering around appearing disoriented. The police tried questioning him, but he appeared to be giving them vague answers.  As he appeared to be confused, he was brought to the ER for examination.

When questioned, he told the psychiatrist that he is a traveling salesman; his wife, who was summoned after confirming his identity through his driver’s license, said that he was a war veteran who had received a gallantry award for his service during the Iraq war. She said that an incident where he was able to rescue two of his fellow mates in an ambush which killed all the others in his group had affected him and he was forced to return home. She said that he was currently unemployed and often went missing for some days and then he used to return home. When she questioned him, he would give vague answers and she suspected that he was either lying or was unable to recollect what had happened.

Upon examination, our psychiatrist makes note of reduced orientation and lack of judging abilities. He makes note that thought processes seem intact with no obsession of thought. He also notes normal psychomotor activity.

Suspecting fugue and to rule out other conditions and trauma, your psychiatrist asks for a CT scan and an EEG. He also asks for urinalysis to see if the person is taking any drugs. Based on the observations made from history, signs and symptoms, mental status examination, physical examination, and from results of tests and imaging studies, your psychiatrist confirms a diagnosis of dissociative fugue.

The care planning will include medical management with antidepressants and anti-anxiety medications. Your psychiatrist will also plan to undertake cognitive behavioral therapy to help overcome the feelings of depression and to overcome the feelings of negativity and help improve social skills and communication.

What to report: You report the evaluation of the patient with 99223 (Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components…). You report the diagnosis with 300.13 if you are using ICD-9 code sets and report F44.1 if you are using the ICD-10 coding system.