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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