Wiki diagnosis code question

[JesseL]

We are a dermatology office. We have a patient that has been picking at his own face to the point that he has a hole in his face. He think's he's trying to get out ingrown hairs. Patient presents with a open wound in his face.

The note says patient exhibits signs and behaviors of self mutilation.

Would you use the code F48.9 (Nonpsychotic mental disorder, unspecified) in this case along with the open wound in face code?

 

[thomas7331]

The code choice of course will depend on what the provider has documented as the patient's condition, but you cannot assign a code for a mental disorder based solely on the fact that the wound was self-inflicted. The provider needs to be the one to document a mental disorder, if in their judgment the patient has one. You can, however, assign an external cause code from the X71-X83 range to indicate intentional self-harm or a purposely self-inflicted injury, if the provider's documentation supports this.

 

[sconnell08]

Hi JesseL,

My first question for you would be if you are able to query the provider. If so, then I would reach out to the provider for further clarification. Given the clinical indicators, there are signs that would be indicative of excoriation (skin-picking) disorder. Of course, you would need to provide other options in that query so that it is not leading. Please see below for a potential query:

Patient presented on (xx/xx/xxxx) with an open wound in his face. The patient states that they have been picking at their own face because they are trying to remove ingrown hairs. Given your clinical understanding of the patient's condition, can their condition be further described as:

• Signs and behaviors of self mutilation
• Excoriation disorder
• Other ____________
• Clinically undetermined

Let me know if you have any questions.