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June 2017Lunch and Learn

Housekeeping Items• All attendees are muted to eliminate background

noise

• Questions will be addressed at the end of the session via “Questions” queue

• Session recording will be provided in the coming day along with a PDF of the slides

• Attendees will receive an certificate of attendance

• AHIMA CEUs can be applied for immediately

• AAPC CEUs will be available in the next several weeks (an email notification will be provided when this is finalized)

Ms. Scott is the current director of coding quality and professional development at TrustHCS. She has vast management, education, coding and auditing expertise. She has over 10 years of management experience, a combined 15 years educating, and 26 years of coding and auditing experience. Throughout her management and coding experience she has also performed coding compliance audits and DRG validation reviews. Her engagements with other HIM professionals have focused on guiding coding efforts to increase accuracy and timeliness. She has experience working with a wide range of HIM departments. This experience allows her to combine her knowledge with real-world experience to drive HIM department efforts and programs.

Today’s PresenterNena Scott, MSEd, RHIA, CCS, CCS-P, CCDS

Learning ObjectivesAfter the completion of this presentation participants will:

• Have increased their knowledge and understanding of the coding guidelines specific to conditions in mental and behavioral health

• Drug and alcohol use, abuse and dependence

• Anxiety and depression

• Bipolar disorder

• Schizophrenia

• Have a basic understanding of the coding of conditions related to Mental Diseases and Disorders, Alcohol/Drug Use and Alcohol/Drug-Induced Organic Mental Disorders in ICD-10-CM and procedures in ICD-10-PCS for coding.

Coding GuidelinesMental, Behavioral and Neurodevelopmental Disorders (F01 – F99)

Pregnancy, Childbirth, and the Puerperium (O00-O9A) - Alcohol and Tobacco Use During Pregnancy, Childbirth and the Puerperium

Chapter 5 – Coding GuidelinesChapter 5: Mental, Behavioral and Neurodevelopmental disorders (F01 – F99)b. Mental and behavioral disorders due to psychoactive substance use1) In Remission Selection of codes for “in remission” for categories F10-F19, Mental and behavioral disorders due to psychoactive substance use (categories F10-F19 with -.21) requires the provider’s clinical judgment. The appropriate codes for “in remission” are assigned only on the basis of provider documentation (as defined in the Official Guidelines for Coding and Reporting).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 abuseIf both abuse and dependence are documented, assign only the code for dependenceIf use, abuse and dependence are all documented, assign only the code for dependenceIf both use and dependence are documented, assign only the code for dependence

3) Psychoactive Substance Use As with all other diagnoses, the codes for psychoactive substance use (F10.9-, F11.9-, F12.9-, F13.9-, F14.9-, F15.9-, F16.9-) should only be assigned based on provider documentation and when they meet the definition of a reportable diagnosis (see Section III, Reporting Additional Diagnoses). The codes are to be used only when the psychoactive substance use is associated with a mental or behavioral disorder, and such a relationship is documented by the provider.

Summarize – “In Remission”• Remission

• Complete cessation of intake

• Period during which decrease towards cessation is actively taking place

• Use of this classification requires the provider’s to documentation and clinical judgment

• Do not assign this classification or status solely based on description of cessation or decrease towards cessation

• Similar to code F10.21, Alcohol dependence, in remission, the selection of codes for “in remission” for categories F11–F19 with -.21 requires the provider’s clinical judgment.

• The appropriate codes for “in remission” are assigned only on the basis of provider documentation (as defined in the ICD-10-CM Official Guidelines for Coding and Reporting).

Chapter 15 – Coding Guidelines

15. Chapter 15: Pregnancy, Childbirth, and the Puerperium (O00-O9A)l. Alcohol and tobacco use during pregnancy, childbirth and the puerperium1) Alcohol use during pregnancy, childbirth and the puerperiumCodes under subcategory O99.31, Alcohol use complicating pregnancy, childbirth, and the puerperium, should be assigned for any pregnancy case when a mother uses alcohol during the pregnancy or postpartum. A secondary code from category F10, Alcohol related disorders, should also be assigned to identify manifestations of the alcohol use.2) Tobacco use during pregnancy, childbirth and the puerperiumCodes under subcategory O99.33, Smoking (tobacco) complicating pregnancy, childbirth, and the puerperium, should be assigned for any pregnancy case when a mother uses any type of tobacco product during the pregnancy or postpartum. A secondary code from category F17, Nicotine dependence, should also be assigned to identify the type of nicotine dependence.

Drug and Alcohol Use, Abuse and Dependence

Coding Guidance - Use, Abuse, and Dependence

If both use 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 abuse and dependence are documented, assign only the code for dependence.

If both use and abuse are documented, assign only the code for abuse.

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• HPI by provider cites discussion with patient about “addiction” to marijuana episodically.

• Provider references as “sense of being addicted” in patient’s terms, and discussed what patient felt he was self-medicating.

• ROS noted positive for anxiety with too much marijuana smoking.

• Provider does not cite anything further in A/P.

• Would this be use, abuse, or dependence?

• USE-intake of drugs confirmed, not classed further

• Does the patient citing possible anxiety or other conditions count as “provider documentation?• NO-Provider does not document a link

between the substance intake and any other condition.

• What code(s) would be acceptable?

• F12.90 Cannabis use, unspecified, uncomplicated

Polling Question

Substance-Induced Mental Disorders

• Drugs and alcohol work by interfering with the way the brain’s nerve cells (neurons) send, receive, and process information.

• Different psychoactive drugs produce different effects and so they are used for many different purposes.

• Medicinally, antidepressant drugs can help relieve feelings of sadness and morphine can relieve pain.

• Recreationally, psychoactive drugs are taken for their pleasant effects. Caffeine, nicotine, marijuana, alcohol, and cocaine are examples of psychoactive drugs commonly used for recreational purposes.

• These same substances also have negative effects; for instance, alcohol can lead to antisocial behavior and most antidepressants have unpleasant side effects.

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Alcohol Abuse and Dependence Alcohol Abuse - DSM-IV defines abuse as a maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by symptoms that do not meet the criteria for Substance Dependence

Alcohol Dependence - DSM-IV defines dependence as a maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by tolerance and withdrawal.

Signs and Symptoms• Social – family disruption, violence, accidents, etc• Physical – frequent infections, hypertension, gastrointestinal problems, seizures, alcohol withdrawal

Treatment• Detoxification, psychotherapy, group therapy and/or 12-step program (AA), and medication (example:

Antabuse causes violent nausea and vomiting when alcohol is consumed)

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Use of Alcohol - Z72.89

• Alphabetic Index routes to an unspecified code from lifestyle problems, for ETOH use, with out further distinction

• Guidelines state for Z72.-

• Note: These codes should be assigned only when the documentation specifies that the patient has an associated problem

Combination Codes - Abuse and DependenceICD-10-CM provides combination codes that include both the alcohol or substance abuse/dependence and any associated complications. Examples include:

F10.231 Alcoholic withdrawal delirium due to alcohol dependence

F10.251 Alcohol-induced psychotic disorder with hallucinations due to alcohol dependence

F10.180 Alcohol-induced anxiety disorder due to alcohol abuse

F11.250 Heroin dependence with heroin-induced psychosis and delusions

Category F19, Other psychoactive substance related disorders, may be used when the specific drug class is not specified.

Example - Coding ScenarioA patient in a state of acute intoxication presented for care. The patient has a 12 year history of alcohol dependence with high levels of daily alcohol consumption. The patient was admitted for alcohol detoxification and rehabilitation. The patient began having withdrawal symptoms with delirium tremors. The patient expressed a desire to reduce his alcohol abuse to a “controlled level”. A motivational treatment plan was developed and implemented, with the short-term goal of assisting the patient in reaching a stable level of use; that is, controlled drinking and a long-range goal of motivating the patient to accept a goal of total abstinence.

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Example - Coding ScenarioDiagnosis Code

Diagnosis: Alcohol dependence with withdrawal and delirium

Step 1 Alphabetic Index look up the main term and subterms

Dependence; Alcohol; with withdrawal; with delirium

Step 2 Verify code in the tabular list

Code F10.231 Alcohol dependence with withdrawal delirium

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Example - Coding ScenarioProcedure Code

Procedure: Alcohol detoxification and rehabilitation

Step 1 Go to the alphabetic index of PCS and look up the main term and subterm(s)

Detoxification Services, for substance abuse (HZ2ZZZZ)

Step 2 Go to the tabular list and verify the code

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Example - Coding Scenario

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Procedure: Individual counseling


Counseling; Individual; Motivational Enhancement (HZ37ZZZ)


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Example Coding Scenario

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Drug Abuse and DependenceMany types of drugs can modify mood or behavior and possibly harm the body when abused.

• The main classification of drugs include:

Stimulants

Opiates

Hallucinogens

Cannabinoids

Steroids

Tobacco

Prescription drugs

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Drug Abuse and Dependence• F11 - Opioid related disorders

• F12 - Cannabis related disorders

• F13 - Sedative, hypnotic or anxiolytic disorders

• F14 - Cocaine related disorders

• F15 - Other stimulant related disorders

• F16 - Hallucinogen related disorders

• F17 - Nicotine dependence

• F18 - Inhalant related disorders

• F19 - Other psychoactive substance related disorders

The 4th character specifies whether the disorder is nondependent abuse (.1), dependent (.2), or unspecified (.9).

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Does Smoker Mean Cigarettes?• No! Smoker means nicotine, but does not expressly indicate cigarettes as the

source of the nicotine, or the method of delivery.

• Smoker codes to F17.200

• Cigarette {nicotine dependence} codes to F17.21- with a 6th character for items like:

• Uncomplicated, Withdrawal, Remission, Specified Disorder

Coding Clinic – Smoker (Tobacco Use vs. Dependence)

Coding Clinic, Fourth Quarter 2013: Page 108 QuestionHow would a documented diagnosis of "smoker" be coded in ICD-10-CM? Should it be coded as tobacco use or dependence? AnswerIn ICD-10-CM, a diagnosis of "smoker" is coded to dependence. Assign code F17.200, Nicotine dependence, unspecified, uncomplicated, when the provider documents "smoker." Please note the following reference in the Alphabetic Index to Diseases: Smoker – see Dependence, drug, nicotine

History of Nicotine DependenceHistory of Dependence

• Nicotine Z87.891

• Use for documented past history of dependence, former smoker, history of smoker

Use of Tobacco

Use of Tobacco – Z72.0

• Note: These codes should be assigned only when the documentation specifies that the patient has an associated problem

• Instructional notes “Use additional code” in found throughout the code sets (COPD, HTN, etc.)

Tobacco Exposure

• Patient presents for follow up visit. Documented conditions of COPD, HTN, etc.

• PFHS populated. Indicates former smoker, and current user of smokeless tobacco. Type of tobacco = chew.

• Provider manages RX, confirms conditions of COPD, HTN. RTC 3 mos.

• Would this be use, abuse, or dependence?• USE – stated by provider & PHX dependence as

“former smoker”• With data in PFSH acceptable as provider

documentation, can we code both the PHX and USE?• YES- each status has distinct code. Use has

instruction for assignment with associated conditions, and COPD, HTN would meet this criteria clinically.

• What code(s) would be acceptable?

• Z87.891 Personal history of nicotine dependence

• Z72.0 Tobacco Use NOS

Polling Question

Key Documentation IssuesKey ICD-10 documentation requirements for severity of illness and intensity of services provided for mental and behavior disorders due to psychoactive substance use:• Specify alcohol and drug use, abuse, or dependence along with intoxication when

applicable• List the specific drug used, abused, or causing a dependence• Specify when alcohol and drug dependence is in remission• Detail any alcohol and drug-induced psychotic disorders such as delusions,

hallucinations, anxiety, sexual dysfunction, sleep disorders, or other types of disorders• Clarify alcohol and drug dependence with withdrawal symptoms such as delirium,

perceptual disturbance, mood disorders, psychotic disorder, persistent amnestic disorder, dementia, or other types of disorders

• Documenting drug use without listing the specific drug(s) will be reported as: “other psychoactive substance/indiscriminate drug use”

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Coding Clinic – Alcohol Abuse and Alcohol Withdrawal

Coding Clinic, Second Quarter 2015: Page 15 QuestionThe Index entry for Alcohol, withdrawal, leads to code F10.239, Alcohol dependence with withdrawal. However, only alcohol abuse is documented by the physician. In ICD-10-CM, how is alcohol abuse with alcohol withdrawal coded? AnswerIn ICD-10-CM, alcohol withdrawal is categorized as alcohol dependence, by default. The classification provides a combination code for alcohol dependence with alcohol withdrawal. Therefore query the provider for clarification, when alcohol abuse and alcohol withdrawal are both documented in the health record.

Coding Clinic – Nicotine Dependence (Uncomplicated, in Remission, with Withdrawal)

Coding Clinic, Fourth Quarter 2013: Page 108 QuestionCan you please define when to use nicotine dependence "uncomplicated", "in remission", "with withdrawal", "with other nicotine-induced disorders" and "with unspecified nicotine-induced disorders? There are currently no ICD-10-CM coding guidelines or ICD-10-CM chapter notes that would assist the medical coder with these definitions. AnswerAlthough nicotine may not typically be thought of as a psychoactive substance, the Official Guidelines for Coding and Reporting, Section I.C.5.c., applies to categories F10-F19, which includes nicotine dependence. The appropriate codes for "in remission," "with withdrawal," etc., within categories F10-F19 are based on provider (as defined in the guidelines) documentation.

Coding Clinic - Electronic Cigarettes Causing Wheezing due to Exposure to Secondhand Smoke

Coding Clinic, Second Quarter 2016: QuestionA child presents to the pediatrician's office with wheezing and coughing. The child does not have any history of asthma, bronchitis or other respiratory problem. Both parents smoke electronic cigarettes in the home. The physician documented that the wheezing and coughing resulted from the child's exposure to secondhand smoke from the e-cigarettes. How should this visit to the pediatrician's office be coded? AnswerAssign code R06.2, Wheezing, as the reason for the visit. Assign codes R05, Cough, and Z77.29, Contact with and (suspected) exposure to other hazardous substances. Since electronic cigarettes do not burn tobacco, they do not produce tobacco smoke. However, while the risk from exposure may be lower, electronic cigarette vapors and exhaled gases may contain certain fine particulate matter and substances that can constitute hazards to health.

Mood or Affective DisordersAffective disorders, more commonly known as mood disorders, are mental disorders with biological, behavioral, social, and psychological factors, characterized by mood disturbance.

Most common affective disorders are:

Bipolar disorders (F31)

Major depressive disorders(F32 – F33)

Anxiety disorders (F40)

Affective disorders are associated with symptoms ranging from the mild to severe and life-threatening.

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Bipolar Disorder (F31)Major affective disorder with abnormally intense mood swings from a hyperactive, or manic, state to a depressive syndrome

Signs and Symptoms

During manic episodes, symptoms include: rapid speech, frequent changes of topic, minimal sleep, excessive amount of energy, impulsive choices, delusions, or auditory hallucinations possible.

During depressive episodes, symptoms include: sad or indifferent mood, slow thoughts and speech, communication avoidance, loss of interest in life, loss of appetite, sleep disturbance, feeling of guilt, threatened or attempted suicide.

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Bipolar TypesBipolar IAt least one manic episode in the patient’s life

Bipolar IIMoods cycling between high and low over time; the "up" moods never reach full-on mania

Rapid CyclingExperiences four or more episodes of mania or depression in one year

Mixed BipolarExperiences both mania and depression simultaneously or in rapid sequence

CyclothymiaMilder symptoms than in full-blown bipolar disorder

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Bipolar Disorder (F31)DiagnosticsA mood questionnaire or checklist to help guide the clinical interview when assessing mood symptoms. In addition, the doctor may order blood and urine tests to rule out other causes of the patient’s symptoms. In a toxicology screening, blood, urine, or hair are examined for the presence of drugs. Blood tests also include a check of thyroid stimulating hormone (TSH) level, since depression is sometimes linked to how the thyroid is functioning.

Treatment

Drug therapy• Lithium carbonate is the drug of choice during an acute phase • Depakote and Tegretol are add-on drugs that may help stabilize manic episodes • Antidepressants

Psychotherapy to encourage personal responsibility, set goals, and establish limits

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This patient was brought to the emergency department by her mother. She has had periods of severe depression for many years. Her medication consisted of Lithium, Synthroid, and Midrin for depression, hypothyroidism, and migraine headaches, respectively. During the past week, however, she became manic, running all her credit cards to the limit, quitting her job, today she tried to strike the cable repair man with a big stick. She was admitted for Lithium adjustment. Diagnoses: Bipolar disorder, mild, manic type, hypothyroidism, and migraine headache

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Diagnosis: Bipolar disorder, mild, manic type


Disorder; bipolar (I), current episode; manic; without psychotic features; mild


Code F31.11 Bipolar disorder, current episode manic without psychotic features, mild

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Diagnosis: Hypothyroidism


Hypothyroidism


Code E03.9 Hypothyroidism, unspecified

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Diagnosis: Migraine headache


Migraine


Code G43.909 Migraine, unspecified, not intractable, without status migrainosus

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Procedure: Medication management


Medication Management GZ3ZZZZ


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Major Depressive Disorder (F32 – F33)

Mood disorder characterized by one or more serious depressive episodes that include deep and persistent sadness, despair, and hopelessness

Signs and Symptoms

Empty or heavy feeling inside, vague sense of loss, self-blame, remorse, guilt, loss of self-esteem, sleep disturbance (insomnia or hypersomnia), loss of concentration and interest in activities, and social withdrawal

Diagnostics

Medical and psychological assessments are needed. It is important to distinguish between reactive depression, which results from a difficult or stressful life experience, and MDD. Depressive mood must be prominent and persistent for a period of at least two weeks with at least four of the previously mentioned symptoms.

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Major Depressive Disorder (F32 – F33)

Treatment

Antidepressants, psychotherapy, electroconvulsive therapy, family support, and education

These disorders are classified as single episode or recurrent with 4th and 5th characters specifying the current severity of the disorder, as follows:

0 – mild

1 – moderate

2 – severe, without psychotic features

3 – severe with psychotic features

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Major Depressive Disorder (F32 – F33)Major Depressive Disorder, single episode of (F32):

Agitated depressionDepressive reactionMajor depressionPsychogenic depressionReactive depression Vital depression

Major Depressive Disorder, recurrent episodes of (F33):Depressive reactionEndogenous depressionMajor depressionPsychogenic depressionReactive depressionSeasonal depressive disorderVital depression

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Key Documentation IssuesMood disorders are categorized in ICD-10 to include:• Manic episode

• Bipolar disorder – specify the current episode as manic, depressed, or mixed

• Major depression – specify as a single or recurrent episode

• Persistent mood [affective] disorder – detail cyclothymic, dysthymic, or other type

Documentation must identify with or without psychotic symptoms or features when applicable

Document if patients are in partial or full remission

Document to identify episodes as mild, moderate, or severe

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Schizophrenia

SchizophreniaSchizophrenia is a group of severe brain disorders in which people interpret reality abnormally. Schizophrenia may result in some combination of hallucinations, delusions, and disordered thinking and behavior.

Signs and Symptoms

Divided into three categories — positive, negative, and cognitive

Positive symptoms - reflect an excess or distortion of normal functions. These active, abnormal symptoms may include: delusions, hallucinations , thought disorder, disorganized behavior

Negative symptoms - refer to a diminishment or absence of characteristics of normal function. They may appear with or without positive symptoms. These include: loss of interest in everyday activities, appearing to lack emotion, reduced ability to plan or carry out activities, neglect of personal hygiene, social withdrawal, loss of motivation

Cognitive symptoms - involve problems with thought processes. These symptoms may be the most disabling in schizophrenia because they interfere with the ability to perform routine daily tasks. These include: problems with making sense of information, difficulty paying attention, and memory problems

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Schizophrenia

Treatment

Antipsychotic medications are the most commonly prescribed treatment for schizophrenia. They are thought to control symptoms by affecting the brain’s neurotransmitters dopamine and serotonin.

Diagnostics

Psychological test (MMPI and some projective tests), brain scans (PET), FMR-1 gene identification, magnetoencepholography (MEG)

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Example - Coding ScenarioThis is a 56-year-old male who was admitted due to decompensating. He thought people were trying to get into his apartment, and he continued to decompensate with his paranoia and persecutory-type delusions, so it was felt that he needed to be hospitalized. During the hospitalization his medications were managed and changed from Zyprexa to Seroquel to Risperdal. The patient did quite well on the Risperdal. The patient was discharged with a final diagnosis of chronic schizophrenia, paranoid type, with acute exacerbation, improved.

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Examples - Coding ScenarioDiagnosis Code

Diagnosis: Paranoid schizophrenia


Schizophrenia; paranoid (type)


Code F20.0 Paranoid schizophrenia

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Example - Coding ScenarioProcedure

Procedure: Medication management


Medication Management GZ3ZZZZ


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Schizoaffective DisorderSchizoaffective disorder is a condition in which a person experiences a combination of schizophrenia symptoms — such as hallucinations or delusions — and of mood disorder symptoms, such as mania or depression.

Signs and Symptoms • Strange or unusual thoughts or perceptions, paranoid thoughts and ideas,

delusions — having false, fixed beliefs, hallucinations, unclear or confused thoughts, manic mood, or a sudden increase in energy and behavioral displays that are out of character, irritability and poor temper control, thoughts of suicide or homicide, problems with attention and memory, lack of concern about hygiene and physical appearance, sleep disturbances such as difficulty falling asleep or staying asleep.

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Schizoaffective DisorderTreatment• People with schizoaffective disorder generally respond best to a combination of

medications and counseling. Treatment varies depending on the type and severity of symptoms, and whether the disorder is depressive-type or bipolar-type.

• Doctors prescribe medications to relieve psychotic symptoms, stabilize mood, and treat depression.

• The only medication approved by the Food and Drug Administration (FDA) for the treatment of schizoaffective disorder is the antipsychotic drug paliperidone (Invega). However, a number of medications approved for the treatment of other mental health conditions may also be helpful for schizoaffective disorder.

• In addition, psychotherapy can help normalize thought patterns, teach social skills, and reduce social isolation.

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Thank YouFor Your Time and Attention!

References• 2017 ICD-10-CM Guidelines:

• Section I.C.5.b.1-3

• Section I.C.15.I.1-2

• Section I.C.15.a.1-6

• AHA Coding Clinics

• 2Q 2016; 2Q 2015; 4Q 2013; 2Q 1991

• AHA Coding Handbook 2016

• TruCode 4Q 2016

• Encoder & Clinotes

Fifth-digit classification for alcohol - drugs

Coding Clinic, Second Quarter 1991 Page: 11

Effective with discharges: April 1, 1991

Fifth-Digit Sub-classification

0 Unspecified

1 Continuous:

Alcohol: Refers to daily intake of large amounts of alcohol or regular heavy drinking on weekends or days off from work.

Drugs: Daily or almost daily use of drug

2 Episodic:

Alcohol: Refers to alcohol binges lasting weeks or months.

Drugs: Indicates short periods between drug use or use on weekends.

3 Remission:

Refers to either a complete cessation of alcohol or drug intake or to the period during which a decrease toward cessation is taking place.

The coder should not attempt to apply these digits without the pattern of use being documented in the medical record. It is common for technical and professional personnel other than the attending physician to provide much of the documentation in facilities dealing with detoxification and rehabilitation, and it is appropriate to accept this documentation for the purpose of assigning fifth digits.

ReferenceAll screen shots used in this document are the property of TruCode (©2017)

http://www.trucode.com. Retrieved from URL.

Association, A. M. (2016). CPT 2016 Professional Edition. American Medical Association.

Centers for Medicare & Medicaid Services (2017). ICD-10 Official Coding Guidelines for Coding and Reporting. 7500 Security Boulevard, Baltimore, MD 21244.

Current Procedural Coding Expert. (2017). Optum.

Leon-Chisen, N. (2017). ICD-10-CM and ICD-10-PCS Coding Handbook. Chicago, IL: AHA Press.

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