Psychiatry Coding & Reimbursement Alert

Hint: List of exclusions is similar to ones used in ICD-9.

When reporting a diagnosis of delusional disorders using ICD-10, you will be able to identify most sub-types with one diagnosis code while you had to use many different codes while reporting these sub-types with ICD-9 codes.

ICD-9: When your clinician arrives at a diagnosis of delusional disorders, you’ll report it using 297.1 (Delusional disorder)with ICD-9 codes. You can use the same diagnosis code if your psychiatrist’s diagnosis is chronic paranoid psychosis, Sander’s disease, or systematized delusions.

Caveat: You cannot use 297.1 if your clinician’s diagnosis is paranoid personality disorders (301.0); acute paranoid reaction (298.3); alcoholic jealousy or paranoid state (291.5) or paranoid schizophrenia (295.3x). You also cannot use this diagnosis code for delusional disorders such as paranoid state simple (297.0); paraphrenia (297.2); shared psychotic disorder (297.3); or for other specific paranoid states such as Paranoia querulans or SensitiverBeziehungswahn (297.8).

ICD-10: When you begin using ICD-10 codes, a diagnosis of delusional disorder that you report with 297.1 in ICD-9 crosswalks to F22 (Delusional disorders). However, unlike ICD-9, you report the same diagnosis code if your clinician’s diagnosis is any of the following:

• Paranoia
• Paranoid state
• Involutional paranoid state
• Paranoid psychosis
• Paraphrenia (late)
• Paranoia querulans
• SensitiverBeziehungswahn
• Delusional dysmorphophobia

Reminder: As in ICD-9, you cannot use F22 if your psychiatrist diagnoses paranoid personality disorder (F60.0); paranoid psychosis, psychogenic (F23); or paranoid reaction (F23). These are “Excludes2” under ICD-10, which means that they are distinct, separately reportable diagnoses. Also, you have a specific ICD-10 code to identify shared psychotic disorder, and this should be reported with F24. Finally, ICD-10 lists the following as “Excludes1” under F22, which means that they are mutually exclusive diagnoses to F22:

• Mood [affective] disorders with psychotic symptoms (F30.2, F31.2, F31.5, F31.64, F32.3, F33.3)
• Paranoid schizophrenia (F20.0)

Focus on These Basics Briefly

Documentation spotlight: Your psychiatrist will arrive at a diagnosis of delusional disorders based on a complete history and a complete evaluation of the patient. Your psychiatrist will perform a complete mental status examination, a complete psychiatric and medical history of the patient and family, and a review of systems.

Some of the findings that your clinician would most likely record in a patient with delusional disorders will include the patient experiencing non-bizarre delusions (delusions about real life situations such as about love, having an illness, about partner’s fidelity, suspicion, etc). While patients suffer from delusions, your psychiatrist will note that the patient’s other thought processes appear to be normal. Your clinician will in most cases note that the patient is well groomed and that functions such as speech and eye contact are generally normal.

When performing a mental status examination, your clinician might note no insight about their delusional behavior. The patient’s condition will usually be observed by another family member, or it might be identified when the patient approaches another doctor for a perceived problem. Your clinician might also note that the patient is irritable, demonstrates aggressive behavior, and suffers from mood disturbances.

Tests: There are no specific tests that your clinician might order to help arrive at the diagnosis of delusional disorders. However, your clinician might order tests such as an x-ray or a CT to rule out other conditions that might demonstrate similar symptoms. Your clinician might also ask for urinalysis to rule out substance abuse.

In most cases, your clinician will rule out other diagnoses (such as schizophrenia; mood disorders; substance abuse; etc.) to arrive at a diagnosis of delusional disorders.

The care planning will include medication management with selective serotonin reuptake inhibitors (SSRIs) or with antipsychotics and cognitive and behavioral psychotherapy. Your clinician might also counsel the family members to help them cope with the patient’s condition and to improve their relationship with the patient, so their interactions will be beneficial in the treatment of the patient.

Example: Your psychiatrist recently reviewed a 36-year-old male patient who was referred to your clinician by his family physician for suspected diagnosis of delusional disorder. The patient was accompanied by his wife. She said that he had been served a restraining order by one of his colleagues whom he had been stalking and whom he suspected of spying on him at the office.

She also told your clinician that these disturbing events had begun about three months ago and that he had once behaved abusively with the colleague about a month ago. She complained that her husband believed that the employee had connived with his boss and that they were planning on throwing him out of work.

Your clinician performed a complete mental status examination, recorded a complete psychiatric and medical history of the patient and family, and performed a review of systems. He noted that the patient appeared stable, was well oriented to place and time, and appeared to be well groomed.

He also noted that the patient had no other abnormalities to thought processes and carried no suicidal or homicidal tendencies. He also observed that the patient appeared to be irritable but did not demonstrate any signs of depression.

Your clinician asks for a urinalysis and CT scan to rule out substance abuse and any other abnormalities. The results of both the tests were normal.

Based on history, signs and symptoms, observations of physical and mental status examination, and the interpretation of the tests, your clinician confirms a diagnosis of delusional disorder.

What to report: You will report the initial diagnostic evaluation that the psychiatrist provided with 90792 (Psychiatric diagnostic evaluation with medical services). You report the diagnosis with 297.1 if you are using ICD-9 codes or report F22 when reporting the diagnosis with ICD-10 codes.