Chapter 5: Mental, Behavioral and Neurodevelopmental disorders(F01 – F99
ICD 10 CM
Chapter 1: Certain Infectious and Parasitic Diseases (A00-B99), U07.1, U09.9
Chapter 2: Neoplasms (C00-D49)
Chapter 3: Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism (D50-D89)
Reserved for future guideline expansion
Chapter 4: Endocrine, Nutritional, and Metabolic Diseases (E00-E89)
Chapter 5: Mental, Behavioral and Neurodevelopmental disorders (F01 – F99)
Chapter 6: Diseases of the Nervous System (G00-G99)
Chapter 7: Diseases of the Eye and Adnexa (H00-H59)
Chapter 8: Diseases of the Ear and Mastoid Process (H60-H95)
Chapter 9: Diseases of the Circulatory System (I00-I99)
Chapter 10: Diseases of the Respiratory System (J00-J99), U07.0
Chapter 11: Diseases of the Digestive System (K00-K95)
Chapter 12: Diseases of the Skin and Subcutaneous Tissue (L00-L99)
Chapter 13: Diseases of the Musculoskeletal System and Connective Tissue (M00-M99)
Chapter 14: Diseases of Genitourinary System (N00-N99)
Chapter 15: Pregnancy, Childbirth, and the Puerperium (O00-O9A)
Chapter 16: Certain Conditions Originating in the Perinatal Period (P00-P96)
Chapter 17: Congenital malformations, deformations, and chromosomal abnormalities (Q00-QA1)
Chapter 18: Symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)
Chapter 19: Injury, poisoning, and certain other consequences of external causes (S00-T88
Chapter 20: External Causes of Morbidity (V00-Y99)
Chapter 21: Factors influencing health status and contact with health services (Z00-Z99)
Chapter 22: Codes for Special Purposes (U00-U85)
Chapter 5: Mental, Behavioral and Neurodevelopmental disorders (F01 – F99)
a. Pain disorders related to psychological factors
Assign code F45.41, for pain that is exclusively related to psychological disorders. As indicated by the Excludes 1 note under category G89, a code from category G89 should not be assigned with code F45.41.
Code F45.42, Pain disorders with related psychological factors, should be used with a code from category G89, Pain, not elsewhere classified, if there is documentation of a psychological component for a patient with acute or chronic pain.
Medycoding Notes
1. Pain disorder exclusively related to psychological factors
Concept: The pain is considered to be entirely caused or maintained by psychological factors, with no significant physical condition accounting for the pain.
Example:
A patient has severe abdominal pain, but extensive evaluation finds no physical condition explaining the pain, and the provider documents that the pain is exclusively related to psychological factors.
2.Pain disorder with related psychological factors
Concept:The patient has a physical/medical condition that causes or contributes to the pain, but psychological factors also affect the severity, duration, or experience of the pain.
Example:
A patient has chronic back pain from a documented spinal condition, but anxiety, depression, or psychological stress is documented as contributing to or worsening the pain.
b. Mental and behavioral disorders due to psychoactive substance use
1) In Remission
Selection of codes describing “in remission” for categories F10-F19, Mental and behavioral disorders due to psychoactive substance use (categories F10-F19 with -.11, -.21, -.91) requires the provider’s clinical judgment and are assigned only on the basis of provider documentation (as defined in the Official Guidelines for Coding and Reporting), unless otherwise instructed by the classification.
Mild substance use disorders in early or sustained remission are classified to the appropriate codes for substance abuse in remission, and moderate or severe substance use disorders in early or sustained remission are classified to the appropriate codes for substance dependence in remission.
2) Psychoactive Substance Use, Abuse and Dependence
When the provider documentation refers to use, abuse and dependence of the same substance (e.g. alcohol, opioid, cannabis, etc.), only one code should be assigned to identify the pattern of use based on the following hierarchy:
• If both use and abuse are documented, assign only the code for abuse
• If both abuse and dependence are documented, assign only the code for dependence
• If use, abuse and dependence are all documented, assign only the code for dependence
• If both use and dependence are documented, assign only the code for dependence.
Medycoding Notes
What is psychoactive substance ?
A psychoactive substance is any substance that acts on the brain and changes a person's mental state, mood, thinking, perception, behavior, or consciousness. Such as Alochol, Cannabis, Opiod etc.
3) Psychoactive Substance Use, Unspecified
As with all other unspecified diagnoses, the codes for unspecified psychoactive substance use (F10.9-, F11.9-, F12.9-, F13.9-, F14.9-, F15.9-, F16.9-, F18.9-, F19.9-) should only be assigned based on provider documentation and when they meet the definition of a reportable diagnosis (see Section III, Reporting Additional Diagnoses). These codes are to be used only when the psychoactive substance use is associated with a substance related disorder (chapter 5 disorders such as sexual dysfunction, sleep disorder, or a mental or behavioral disorder) or medical condition, and such a relationship is documented by the provider.
4) Medical Conditions Due to Psychoactive Substance Use, Abuse and Dependence Medical conditions due to substance use, abuse, and dependence are not classified as substance-induced disorders. Assign the diagnosis code for the medical condition as directed by the Alphabetical Index along with the appropriate psychoactive substance use, abuse or dependence code. For example, for alcoholic pancreatitis due to alcohol dependence, assign the appropriate code from subcategory K85.2, Alcohol induced acute pancreatitis, and the appropriate code from subcategory F10.2, such as code F10.20, Alcohol dependence, uncomplicated. It would not be appropriate to assign code F10.288, Alcohol dependence with other alcohol-induced disorder.
5) Blood Alcohol Level
A code from category Y90, Evidence of alcohol involvement determined by blood alcohol level, may be assigned when this information is documented and the patient’s provider has documented a condition classifiable to category F10, Alcohol related disorders. The blood alcohol level does not need to be documented by the patient’s provider in order for it to be coded.
c. Factitious Disorder
Factitious disorder imposed on self or Munchausen’s syndrome is a disorder in which a person falsely reports or causes his or her own physical or psychological signs or symptoms. For patients with documented factitious disorder on self or Munchausen’s syndrome, assign the appropriate code from subcategory F68.1-, Factitious disorder imposed on self.
Munchausen’s syndrome by proxy (MSBP) is a disorder in which a caregiver (perpetrator) falsely reports or causes an illness or injury in another person (victim) under his or her care, such as a child, an elderly adult, or a person who has a disability. The condition is also referred to as “factitious disorder impose on another” or “factitious disorder by proxy.” The perpetrator, not the victim, receives this diagnosis. Assign code F68.A, Factitious disorder imposed on another, to the perpetrator’s record. For the victim of a patient suffering from MSBP, assign the appropriate code from categories T74, Adult and child abuse, neglect and other maltreatment, confirmed, or T76, Adult and child abuse, neglect and other maltreatment, suspected.
d. Dementia
The ICD-10-CM classifies dementia (categories F01, F02, and F03) on the basis of the etiology and severity (unspecified, mild, moderate or severe). Selection of the appropriate severity level requires the provider’s clinical judgment and codes should be assigned only on the basis of provider documentation (as defined in the Official Guidelines for Coding and Reporting), unless otherwise instructed by the classification. If the documentation does not provide information about the severity of the dementia, assign the appropriate code for unspecified severity.
If a patient is admitted to an inpatient acute care hospital or other inpatient facility setting with dementia at one severity level and it progresses to a higher severity level, assign one code for the highest severity level reported during the stay.
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