Coding for mental and behavioral disorders in ICD-10-CM will depend on the documentation found in the medical record. Working with clinicians on the new coding system and the expanded codes will allow for clarity in documentation so correct codes can be assigned.
Depression
Depression (also referred to as clinical depression, dysthymic disorder, major depressive disorder or unipolar depression) is a disorder of the brain with a variety of causes (genetic, environmental, psychological, and biochemical) that affects over 20 million people in the United States. Depression usually starts between the ages of 15 and 30, and is more common in women. It can result in increased work absenteeism, short-term disability, and decreased productivity, and may also adversely affect the course and outcome of common chronic conditions, such as arthritis, asthma, cardiovascular disease, cancer, diabetes, and obesity.
The ICD-10 classification of Mental and Behavioral Disorders, developed in part by the American Psychiatric Association (APA), classifies depression by code. Typically the patient suffers from lowering of mood, reduction of energy, and a decrease in activities. The patient’s capacity for enjoyment, interest, and concentration is reduced and is marked by tiredness after even a minimum of effort. Sleep patterns are usually disturbed, appetite is diminished, and self-confidence and self-esteem are reduced. Depending on the number and severity of the symptoms, a depressive episode may be specified as mild, moderate, or severe.
For mild depressive episodes, two or three symptoms are usually present.
A. The general criteria for depressive episode must be met.
B. At least two of the following three symptoms must be present:
- Depressed mood to a degree that is definitely abnormal to the individual, present for most of the day and almost every day, largely uninfluenced by circumstances, and sustained for at least two weeks
- Loss of interest or pleasure in normally pleasurable activities
- Decreased energy or increased fatigue
C. An additional symptom or symptoms from the following list should be present to give a total of at least four:
- Loss of confidence or self-esteem
- Unreasonable feelings of self-reproach or excessive and inappropriate guilt
- Recurrent thoughts of death or any suicidal behavior
- Complaints or evidence of diminished ability to think or concentrate, such as indecisiveness or vacillation
- Change in psychomotor activity, with agitation or retardation (either subjective or objective)
- Sleep disturbance of any type
- Change in appetite (decrease or increase) with corresponding weight change
For moderate depressive episodes, four or more of the symptoms noted above are usually present and the patient is likely to have great difficulty in continuing with ordinary activities.
For severe depressive episodes without psychotic symptoms, several of the above symptoms are marked and distressing—typically loss of self-esteem and ideas of worthiness or guilt. Suicidal thoughts and acts are common. A number of somatic symptoms are usually present.
For major depressive disorders, ICD-10-CM includes:
- Agitated depression
- Major depression} single episode without psychotic symptoms
- Vital depression
ICD-10-CM classifies depression by episodes and types (such as mild, moderate, severe, and with or without psychotic features).
ICD-10-CM Example:
F32.2 Major depressive disorder, single episode, severe without psychotic features
ICD-10-CM also includes codes for recurrent depressive disorders, as well as those in remission or partial remission. A recurrent depressive disorder is characterized by:
- Repeated episodes of depression without any history of independent episodes of mood elevation and increased energy or mania
- At least one previous episode lasting a minimum of two weeks and separated by the current episode of at least two months
- No past hypomanic or manic episodes
For a classification of “in remission,” the patient has had two or more depressive episodes in the past, but has been free from depressive symptoms for several months. This category can still be used if the patient is receiving treatment to reduce the risk of further episodes.
ICD-10-CM Examples:
F33.0 Major depressive disorder, recurrent, mild
F33.41 Major depressive disorder, recurrent, in partial remission
Bipolar Disorder
Bipolar disorder is a serious mental illness. People who have it experience dramatic mood swings. They may go from overly energetic, “high” and/or irritable, to sad and hopeless, and then back again. They often have normal moods in between. The up feeling is called mania. The down feeling is depression.
Bipolar disorder can run in families. It usually starts in late adolescence or early adulthood. A medical checkup can rule out other illnesses that might cause the mood changes. Repeated episodes of hypomania or mania only are classified as bipolar. It includes manic-depressive illness, psychosis, or reaction.
In ICD-10-CM, bipolar I is classified as to whether the patient’s current episode is hypomanic, manic, and with or without psychotic symptoms.
A hypomanic episode is characterized by a persistent mild elevation of mood, increased energy and activity, and is usually marked by feelings of well being and both physical and mental efficiency. Increased sociability, talkativeness, over-familiarity and increased sexual energy, and a decreased need for sleep are often present.
A manic episode is characterized by mood elevated out of keeping with the patient’s circumstances, and may vary from carefree joviality to almost uncontrollable excitement. Elation is accompanied by increased energy, resulting in over-activity, pressure of speech, and a decreased need for sleep. Attention cannot be sustained and there is often distractibility. Loss of social inhibitions may result in behavior that is reckless, foolhardy, or inappropriate for the circumstances, and out of character for the patient. In some manic episodes, the mood is one of irritability or suspiciousness rather than elation.
Bipolar II is similar to bipolar I disorder, with moods cycling between high and low over time; however, with bipolar II disorder, the “up” moods never reach full-on mania. The less-intense elevated moods in bipolar II disorder are called hypomanic episodes, or hypomania. A person affected by bipolar II disorder has had at least one hypomanic episode in life. Most people with bipolar II disorder also suffer from episodes of depression. This is where the term “manic depression” comes from.
In between episodes of hypomania and depression, many people with bipolar II disorder live normal lives.
ICD-10-CM Examples:
F31.11 Bipolar disorder, current episode manic without psychotic features, mild
F31.64 Bipolar disorder, current episode mixed, severe, with psychotic features
F31.8 Bipolar II disorder
Cyclothymia and Dysthymia
Cyclothymia is a persistent instability of mood involving numerous periods of depression and mild elation, none of which is sufficiently severe or prolonged to justify a diagnosis of a bipolar or recurrent depressive disorder. This disorder is often found in the relatives of bipolar patients, some of whom eventually develop bipolar disorder.
Dysthymia is a chronic depression of mood, lasting at least several years. It is not severe, and episodes are not prolonged enough to justify a diagnosis of severe, moderate, or mild recurrent depressive disorders.
ICD-10-CM Examples:
F34.0 Cyclothymic disorder
F34.1 Dysthymic disorder
Mental and behavioral disorders can be grave in their consequences, and affect hundreds of millions of people worldwide. Coders will require a comprehensive understanding of these disorders to extract the appropriate information from medical record documentation for ICD-10 code treatment and diagnostic assignment.
Rhonda Buckholtz, CPC, CPMA, CPC-I, CENTC, CGSC, COBGC, CPEDC, is vice president of ICD-10 Training and Education at AAPC.