Coding, Classification and Reimbursement

Behavioral Health Diagnosis

  • 1.  Behavioral Health Diagnosis

    Posted 12-13-2018 16:39
    ​Hello All, I have a question regarding what code to use under ICD-10 under behavioral health situations.  1) What ICD -10 code would be used if staff are unable to diagnosis a patient?  2) What ICD-10 code would staff use if the diagnosis is deferred?   The setting is an outpatient behavioral health clinic.  We are having some debate on the appropriate.  The debate is whether to use Z71.1, R69 or Z03.89.  Thank for your help.

    Michelle Lakins-Waller
    Compliance Officer

  • 2.  RE: Behavioral Health Diagnosis

    Posted 12-14-2018 08:52
    I would think that the signs and symptoms would be reported until the patient has been properly diagnosed.    I am thinking of this as a syndrome that does not have a specific code where the manifestations are reported.

    Laurie Johnson, MS, RHIA, FAHIMA
    AHIMA Approved ICD-10-CM/PCS Trainer
    Healthcare Consultant

  • 3.  RE: Behavioral Health Diagnosis

    Posted 12-24-2018 11:44

    I would also use a sign and symptom based on the 2019 ICD-10 Guidelines Section IV.D. states sign and symptom codes can be used, as opposed to diagnoses, when a diagnosis has not been established (confirmed by provider).

    Also look at H. Uncertain Diagnosis under Section IV. as there is a note regarding psychiatric hospitals and this could change your coding.

    Best Regards,

    Megan Del Rio
    His Discharge Coder

  • 4.  RE: Behavioral Health Diagnosis

    Posted 12-28-2018 21:15
    I use the Z code for homeless if that is the reason for having trouble with placement. If patient is waiting for a bed to open in a long term facility I change the discharge status appropriately to reflect where the patient goes (rehab, long term psych, etc.).

    Theresa Guerra, RHIT
    HIM Coder