Updated on: November 21, 2016

Does Your Documentation Have Attention Deficit Disorder?

Original story posted on: April 27, 2015

Editor’s Note: This is the sixth article in the continuation of a series of articles on clinical documentation improvement by clinical service. 

With the repeal of the sustainable growth rate (SGR) in the recently passed H.R. 2 bill, it appears that ICD-10 implementation is on again.

Taking into consideration the weekends and holidays between now and Oct. 1, 2015, we barely have 90 working days to prepare for the adventure. Hopefully we will be able to maintain our sanity! Mental and behavioral health codes have undergone major revisions and may present some challenges under ICD-10-CM/PCS. What are the required documentation updates? Let’s take a look at some examples.


In reviewing diagnoses that are complications/comorbid conditions, it appears that there aren’t any behavioral health or mental disorders that are major complication/comorbid conditions, based on the V32 MS-DRG Definitions Manual. Another observation is that Diagnostic & Statistical Manual – 5th Revision (DSM-5) is compatible with ICD-10-CM. This terminology set was adopted in May 2013 to provide consistency in diagnosing and treating mental and behavioral health patients.

Drug use, abuse, and dependence: These terms tend to be used interchangeably, but there is an important difference. Dependence represents a complication/comorbid condition (CC) while use and abuse do not, unless they are further qualified with these terms specified as additional manifestations – drug induced-disorder with intoxication delirium or withdrawal, for example. The provider must document these terms so that the corresponding codes can be assigned, according to a 2013 publication of Coding Clinic. The ICD-10-CM Official Guidelines for Coding and Reporting also provide guidance when the documentation includes use, abuse, and dependence for the same drug or alcohol. If use and abuse are documented, then the code for abuse will be assigned. If abuse and dependence are documented, then the code for dependence will be assigned. If use, abuse, and dependence are documented, then only dependence will be assigned. The key to this concept is that the physician must understand that there is a difference in code assignment for these conditions.

Schizophrenia: There are several types of schizophrenia – paranoid, disorganized, catatonic, and residual. Any of these types will impact the MS-DRG assignment, but if the provider only documents schizophrenia, the opportunity is lost for another complication/comorbid condition.

Mental disorders: depression unspecified is now classified as a major depressive disorder, unspecified. Additional terms that can be documented include agitated, with adjustment disorder, with anxiety, psychotic, nervous, or neurotic. Frequency can also be included in a single episode or recurrent episodes with the acuity of mild, moderate, or severe. Mood disorders can be further specified by including acuity – mild, moderate, severe, or severe with psychotic features. The same is true for bipolar disorders, which can include the details regarding recurrence – single episode, recurrent episode, or in remission. Bipolar disorders also include the presentation – currently depressed, currently manic, currently hypomanic, or currently mixed (manic and depressed).

Mental conditions related to physiological conditions: These conditions are related to a medical condition such as cerebrovascular disorder or traumatic brain injury. The medical conditions may show manifestations related to behavior. Provider documentation should include aggressive behavior, combative behavior, or violent behavior, which frequently is associated with dementia. 

Intellectual disabilities: This condition was previously classified as mental retardation. The severity of the intellectual disability should be documented. The acuity includes mild, moderate, severe, and profound. The classification of severe and profound may impact the MS-DRGs, as these are identified as CCs. 

Rehabilitative procedures: The procedures for alcohol and drug rehabilitation include individual counseling, group counseling, and individual psychotherapy. The various types of counseling include confrontational, spiritual, vocational, psycho-educational, motivational enhancement, 12-step, behavioral, cognitive, cognitive-behavioral, continuing care, and interpersonal. It would be important to review the documentation so that the appropriate documentation is used to assign the correct procedure code.

Electroconvulsive therapy (ECT): ECT is classified according to the frequency of the induced seizure and if the ECT is performed unilaterally or bilaterally. This documentation may require updating in the electronic health record so that the procedure can be appropriately coded.   

This exploration of mental health and behavioral medicine indicates that there are some changes regarding these conditions and procedures. The American Psychiatric Association has worked to ensure that there is consistency between ICD-10-CM and DSM-5. It is important that the documentation is specific regarding the patient’s presentation and any associated conditions, manifestation, and severity.  

The next article’s topic will be dermatology.


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.
Laurie M. Johnson, MS, RHIA, FAHIMA AHIMA Approved ICD-10-CM/PCS Trainer

Laurie M. Johnson, MS, RHIA, FAHIMA, AHIMA Approved ICD-10-CM/PCS Trainer is currently a senior healthcare consultant for Revenue Cycle Solutions, based in Pittsburgh, Pa. Laurie is an American Health Information Management Association (AHIMA) approved ICD-10-CM/PCS trainer. She has more than 35 years of experience in health information management and specializes in coding and related functions. She has been a featured speaker in over 40 conferences. Laurie is a member of the ICD10monitor editorial board and makes frequent appearances on Talk Ten Tuesdays.

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