February 16, 2015

ICD-10-PCS Coding of Significant Procedures: Behavioral Health Services

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The Uniform Hospital Discharge Data Set (UHDDS) outlines the hospital reporting requirements for all inpatient discharges. The UHDDS reporting requirements will remain in effect on and after Oct. 1, 2015, when ICD-10-CM/PCS is scheduled to be implemented.

One data element that hospitals are required to report is the significant procedures performed during each inpatient stay.

 

A significant procedure is one that is:

• Surgical in nature, or

• Carries a procedural risk, or

• Carries an anesthetic risk, or

• Requires specialized training.

Since one of the goals of ICD-10-CM/PCS implementation is to improve the collection of healthcare data, no hospital can afford to under-report UHDDS data elements. Unfortunately, some hospitals do not currently consistently assign procedure codes to (and, as a result, do not report) significant procedures. 

A series of articles based on previously held Web-based training presentations has been prepared to provide clinical documentation guidance for non-operating room and bedside procedures that should be assigned an ICD-10-PCS code if they meet the UHDDS significant procedure definition provided above.

Behavioral health therapy documentation and policy checklist:

  1. In which medical record document is behavioral health therapy reported?
  2. In the medical record document, is the type of behavioral health therapy or service documented?

Such services could include the following:

*       Biofeedback

*       Counseling

*       Crisis intervention

*       Electroconvulsive therapy

*       Family psychotherapy

*       Group psychotherapy

*       Hypnosis

*       Individual psychotherapy

*       Light therapy

*       Medication management

*       Narcosynthesis

*       Psychological testing

Psychological testing documentation and policy checklist:

  1. In which medical record document is psychological testing reported?
  2. In the medical record document, is each psychological test categorized as one of the following?

*       Developmental

*       Personality/behavioral

*       Intellectual/psychoeducational

*       Neuropsychological

*       Neurobehavioral/cognitive status

Individual psychotherapy documentation and policy checklist:

  1. In which medical record document are individual psychotherapy services reported?
  2. Is the type of individual psychotherapy documented in the medical record?

Such services could include the following:

*       Behavioral

*       Cognitive

*       Cognitive-behavioral

*       Interactive

*       Interpersonal

*       Psychoanalysis

*       Psychodynamic

*       Psychophysiological

*       Supportive

Electroconvulsive therapy documentation and policy checklist:

  1. In which medical record document is electroconvulsive therapy (ECT) reported?  
  2. Is the type of ECT and number of sessions documented in the medical record?

*       Unilateral - Single Seizure

*       Unilateral – Multiple Seizures

*       Bilateral – Single Seizure

*       Bilateral – Multiple Seizures

*       Other electroconvulsive therapy (specify)

Medication management documentation and policy checklist:

  1. In which medical record document(s) are psychotherapeutic medications reported?
  2. Is each psychotherapeutic medicationdocumented in the medical record?
  3. Is the route and approach used to administer each psychotherapeutic medication documented in the medical record?

Such services could include the following:

*       Inhalation

*       Intra-arterial

*       Intradermal

*       Intramuscular

*       Intrathecal

*       Intravenous - Central Vein, Open

*       Intravenous - Central Vein, Percutaneous

*       Intravenous - Peripheral Vein, Open

*       Intravenous - Peripheral Vein, Percutaneous

*       Iontophoresis

*       Subcutaneous

 

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.
Lolita M. Jones, RHIA, CCS

Lolita M. Jones, RHIA, CCS, is the principal of Lolita M. Jones Consulting Services (LMJCS), founded in October 1998 in Fort Washington, MD. Ms. Jones has over 25 years of experience in coding and consulting. She started preparing for the implementation of ICD-10-CM/PCS by going back to school. On September 12, 2010, Ms. Jones became an AHIMA-approved ICD-10-CM/PCS trainer.

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