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

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