Updated on: November 21, 2016

Coding Schizophrenia: Mental Health Assessments Require Specificity

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Original story posted on: June 1, 2015

EDITOR’S NOTE: Kathy Pride is continuing her reporting on diseases that have been covered in the national news media as they relate to ICD-10.The recent death of American mathematician and Nobel Prize winner John Forbes Nash, Jr., in partial recovery from schizophrenia, prompted this article.

Dr. John Forbes Nash Jr., the Nobel Prize-winning mathematician whose work included non-cooperative game theory, tragically died this past week in a car crash at the age of 86. His work and life were the subject of the Academy Award-winning 2001 film “A Beautiful Mind” starring Russell Crowe, which put into focus the stigma associated with schizophrenia. Nash's famed work in math and other fields extended beyond the game theory work that won him the Nobel Prize.

Many of you have likely seen the movie, but what do we coders really know about schizophrenia, and how is it coded in ICD-10-CM? Let’s start with this: what is schizophrenia? According to the National Institute of Health, schizophrenia is a chronic, severe, and disabling brain disorder that has affected people throughout history.

People with the disorder may hear voices other people don't hear. They may believe that other people are reading their minds, controlling their thoughts, or plotting to harm them. This can terrify people with the illness and make them withdrawn or extremely agitated.

People with schizophrenia may not make sense when they talk. They may sit for hours without moving or talking. Sometimes people with schizophrenia seem perfectly fine until they talk about what they are really thinking.

Experts think schizophrenia is caused by several factors. The foremost of these factors are genes and environment. Scientists have long known that schizophrenia runs in families. The illness occurs in 1 percent of the general population, but it occurs in 10 percent of people who have a first-degree relative with the disorder, such as a parent, brother, or sister. People who have second-degree relatives (aunts, uncles, grandparents, or cousins) with the disease also develop schizophrenia more often than the general population.

The risk is highest for an identical twin of a person with schizophrenia. He or she has a 40 to 65 percent chance of developing the disorder.

In addition, researchers believe it takes more than genes to cause the disorder. Scientists think interactions between genes and the environment are necessary for schizophrenia to develop. Many environmental factors may be involved, such as exposure to viruses or malnutrition before birth, problems during birth, and other not-yet-known psychosocial factors.

Schizophrenia is an equal-opportunity disease, as it affects men and women equally, and it occurs at similar rates in all ethnic groups around the world. Symptoms such as hallucinations and delusions usually start between the ages of 16 and 30. Men tend to experience symptoms a little earlier than women. Most of the time, people do not get schizophrenia after age 45. Schizophrenia rarely occurs in children, but awareness of childhood-onset schizophrenia is increasing.

Coding Schizophrenia in ICD-10

Every coder knows that we can only code what is documented. Mental health providers typically do a great job at documenting the elements needed to code to the highest level of specificity, but often our primary care and specialty physicians will list a mental health diagnosis in the patient’s assessment and fail to document the specificity needed to code properly, leaving the coder with no choice but to select an unspecified code. 

To document and subsequently code schizophrenia in ICD-10-CM, let’s first take a look at what is different between ICD-9-CM and ICD-10-CM. In ICD-9-CM, schizophrenia has two classifications. The first classifies the subtype of schizophrenia – these subtypes are categorized as simple, disorganized, catatonic, paranoid, schizophreniform disorder, latent schizophrenia, residual, schizoaffective disorder, and “other” specified type of schizophrenia. The second classification in ICD-9-CM is the acuity: subchronic, chronic, subchronic with acute exacerbation, chronic with acute exacerbation, and in remission.

According to DSM-5, the diagnostic criteria no longer identify subtypes or acuity. Subtypes had been defined by the predominant symptom at the time of evaluation. But these were not helpful to clinicians, because patients’ symptoms often changed from one subtype to another and presented overlapping subtype symptoms, which blurred distinc­tions among the subtypes and decreased their validity. ICD-10-CM eliminated the acuity of schizophrenia; however, it did not eliminate the subtype. Therefore, ICD-10-CM diagnoses codes are not in harmony with DSM-5. 

However, ICD-10-CM did update the schizophrenia subtypes from the ICD-9-CM classification. The ICD-10-CM category for schizophrenia (F20) includes the subtypes paranoid, disorganized, catatonic, undifferentiated, residual, and “other.” 

Schizophrenia Subtypes

ICD-9-CM

  • Simple
  • Disorganized
  • Catatonic
  • Paranoid
  • Schizophreniform
  • Latent
  • Residual
  • Schizoaffective
  • Other

ICD-10-CM

  • Paranoid
  • Disorganized
  • Catatonic
  • Undifferentiated
  • Residual
  • Other

Other new categories in ICD-10-CM previously classified under schizophrenia in ICD-9-CM are the following:

  • F21 – Schizotypal disorder, which includes borderline, latent, prepsychotic, prodromal, pseudoneurotic, and pseudopsychopathic schizophrenia, as well as schizotypal personality disorder
  • F25 – Schizoaffective disorder, which includes bipolar and depressive types

Look for ICD-11 to finally harmonize the schizophrenia codes with DSM-5.

Of course, by the time we get to ICD-11, the psychiatric community will likely have moved on to DSM-6. 

About the Author

Kathy Pride, CPC, RHIT, CCS-P, is vice president of coding and documentation services for Panacea Healthcare Solutions. Kathy has extensive experience in management, project implementation, coding, billing, physician documentation improvement, compliance audits and education. She is also an approved ICD-10 Trainer through the American Health Information Management Association (AHIMA) and a previous member of the AAPC National Advisory Board (1998 – 2000).

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Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.
Kathy Pride, CPC, RHIT, CCS-P, AHIMA-Approved ICD-10-CM/PCS Trainer

Kathy is a proven leader in healthcare revenue cycle management with extensive experience in management, project implementation, coding, billing, physician documentation improvement, compliance audits, and education. She has trained and managed Health Information Management (HIM) professionals in multiple environments. She is currently the Senior Vice President of Coding and Documentation Services for Panacea Healthcare Solutions. Kathy has provided compliance auditing and documentation education to hundreds of physicians and coders throughout her career.

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