Coding, Classification and Reimbursement

​​Patient presents for alcohol detox and severe depression. On the Comprehensive Psychiatric Evaluation, physician notes that patient is currently have Visual and Auditory Hallucinations. But only list Alcohol use disorder and Major depressive disorder as diagnosis.
Is there a guideline for coding documented abnormal thought content (psychosis nos, hallucinations, delusions, etc) that is not directly tied to a specific mental health diagnosis. I do not want to use a R code. I was tagged in a recent audit for that. But that time the only diagnosis to tie it to was MDD. This current situation I have either ETOH or MDD to choose from.

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Theresa Guerra, RHIT
HIM Coder
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I would check to see if anywhere the hallucinations were caused by alcohol. I've only had one case where they were in the past few months. If they were not caused by alcohol then it could be MDD with psychotic symptoms. The doctors should be documenting this, but might need a reminder.

In the guidelines Section 1.A.ch 18 b. states "signs or symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification". Hallucinations would fall under F10.151 & 251 or F 32.3 & F33.3.

Hope that helps a little.

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Megan Del Rio
His Discharge Coder
mparnt@gmail.com
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Original Message:
Sent: 11-19-2018 16:24
From: Theresa Guerra
Subject: Hallucinations

​​Patient presents for alcohol detox and severe depression. On the Comprehensive Psychiatric Evaluation, physician notes that patient is currently have Visual and Auditory Hallucinations. But only list Alcohol use disorder and Major depressive disorder as diagnosis.
Is there a guideline for coding documented abnormal thought content (psychosis nos, hallucinations, delusions, etc) that is not directly tied to a specific mental health diagnosis. I do not want to use a R code. I was tagged in a recent audit for that. But that time the only diagnosis to tie it to was MDD. This current situation I have either ETOH or MDD to choose from.

------------------------------
Theresa Guerra, RHIT
HIM Coder
------------------------------

Original Message------

I would check to see if anywhere the hallucinations were caused by alcohol. I've only had one case where they were in the past few months. If they were not caused by alcohol then it could be MDD with psychotic symptoms. The doctors should be documenting this, but might need a reminder.

In the guidelines Section 1.A.ch 18 b. states "signs or symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification". Hallucinations would fall under F10.151 & 251 or F 32.3 & F33.3.

Hope that helps a little.

------------------------------
Megan Del Rio
His Discharge Coder
mparnt@gmail.com
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