Coding spotlight: Mental disorders in childhood
Mental disorders among children may cause serious changes in the way children typically learn, behave or handle their emotions, which cause distress and problems getting through the day. Healthcare professionals use the guidelines in the American Psychiatric Association’s Diagnostic and Statistical Manual, Fifth Edition (DSM-5),1 to help diagnose mental health disorders in children.
The most common mental disorders of childhood and adolescence fall into the following categories:
- Anxiety disorders (generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, phobic disorder)
- Posttraumatic stress disorder (PTSD)
- Separation anxiety disorder
- Social anxiety disorder
- Obsessive-compulsive disorder
- Bipolar disorder
- Disruptive behavioral disorders (attention-deficit/hyperactivity disorder ADHD, conduct disorder, and oppositional defiant disorder)
- Eating disorders
- Schizophrenia (less common).
Other conditions and concerns that affect children’s learning, behavior and emotions include learning and developmental disabilities, autism, and risk factors like substance use and self-harm.
- Chapter 5 of the ICD-10-CM code set categorizes mental disorders.
- Codes from chapter 5 are assigned based on the express documentation of the provider’s clinical judgment regarding the patient’s mental or behavioral disorder(s). The codes are not assigned based on symptoms, signs, or abnormal clinical laboratory findings.
Major depressive disorder (MDD) is classified in ICD-10-CM as:
- F32: Major depressive disorder, single episode
- F33: Major depressive disorder, recurrent
When documenting major depressive disorder, keep in mind that proper and specific coding requires clear documentation of the:
- Episode: single versus recurrent.
- Severity: mild, moderate, or severe.
- Psychotic features, when present.
- Status of remission as either partial or full.
Remember to document any established causality between multiple mental health conditions. For example:
- Suppose the patient has a diagnosis of depression and a diagnosis of anxiety with a causal relationship between the two conditions. In such cases, documentation must establish the relationship by stating depression with, due to, or related to anxiety
ICD-10-CM classifies bipolar disorders under the following categories:
- F30: Manic episode (bipolar disorder, single manic episode, and mixed affective episode)
- F31: Bipolar disorder (manic-depressive illness, manic-depressive psychosis, and manic-depressive reaction)
- F34: Persistent mood affective disorders (cyclothymic disorder and dysthymic disorder)
- F39: Unspecified mood affective disorder (affective psychosis not otherwise specified).
Nonpsychotic mental disorders
Anxiety, dissociative, stress-related, somatoform and other nonpsychotic mental disorders are classified in categories F40 to F48.
Anxiety disorders are classified in ICD-10-CM under the following categories:
- F40: Phobic anxiety disorders
- F41: Other anxiety disorders
- F42: Obsessive-compulsive disorder.
Reactions to stress
ICD-10-CM provides category F43 for coding reactions to severe stress and adjustment disorders. Code F43.0, Acute stress reaction, classifies acute reaction to stress, including acute crisis reaction, crisis state, and psychic shock.
Posttraumatic stress disorder (PTSD) is classified in ICD-10-CM to subcategory F43.1, with fifth-characters for unspecified, acute, or chronic.
Adjustment disorders are classified to subcategory F43.2, with the fifth-character axis being the nature of the reaction, such as anxiety, depression, or other symptoms. For example:
- F43.24: Child adopted from a foreign country, suffering from culture shock with conduct disturbance.
Behavioral syndromes associated with physiological disturbances and physical factors
Categories F50 to F59 are devoted to behavioral syndromes associated with physiological disturbances and physical factors. These codes are not assigned when the conditions are present due to mental disorders classified elsewhere or organic in origin. This grouping includes, for example:
- F50.: Eating disorders (such as anorexia nervosa and bulimia nervosa)
- F51.: Sleep disorders, not due to a substance or known physiological condition
- F54*: Psychological and behavioral factors associated with disorders or diseases classified elsewhere
- F59: Unspecified behavioral syndromes associated with physiological disturbances and physical factors
* Code F54 classifies psychological and behavioral factors associated with diseases classified elsewhere. Typical conditions that are often associated with code F54 include asthma and dermatitis.
- Those types of disorders are classified in category F20, with a fourth character indicating the type of schizophrenia.
- The codes from category F20 are followed by an excludes one note indicating they should not be reported with codes classifying a brief psychotic disorder (F23) , cyclic schizophrenia (F25.0), schizoaffective disorder (F25-F25.9) and schizophrenic reaction not otherwise specified (NOS) (F23).
- Assign code F20.9, Schizophrenia, unspecified, for chronic schizophrenia with acute exacerbation. The existing ICD-10-CM codes for schizophrenia do not differentiate severity or an acute exacerbation (AHA Coding Clinic, Second Quarter 2019, p.32).
Attention deficit hyperactivity disorder (ADHD)
ICD-10-CM codes for ADHD include:
- F90.0: Attention-deficit hyperactivity disorder, predominantly inattentive type.
- F90.1: Attention-deficit hyperactivity disorder, predominantly hyperactive type.
- F90.2: Attention-deficit hyperactivity disorder, combined type.
- F90.8: Attention-deficit hyperactivity disorder, other types.
- F90.9: Attention-deficit hyperactivity disorder, unspecified type.
The ADHD diagnosis may not be established at the time of the initial physician office visit. Therefore, it may take two or more visits before the diagnosis is confirmed or ruled out.
ICD-10-CM outpatient coding guidelines specify not to assign a diagnosis code when documented as rule out, working diagnosis or other similar terms indicating uncertainty.
Instead, the outpatient coding guidelines instruct to code the condition(s) to the highest degree of certainty for that encounter/visit, requiring the use of codes that describe symptoms, signs or another reason for the visit.
History codes (categories Z80 to Z87) may be used as secondary codes if the historical condition or family history impacts current care or influences treatment. Personal and family history of ADHD has an impact on the clinical assessment of an individual for this disorder; the ICD-10-CM codes to report the history of ADHD in an individual include:
- Z86.59: Personal history of other mental and behavioral disorders.
- Z81.8: Family history of other mental and behavioral disorders.
ICD-10-CM provides codes for behaviors that are not classified as behavioral disorders, such as:
- R41.840: Attention and concentration deficit
- R45.83: Excessive crying of child, adolescent, or adult
- R45.87: Impulsiveness
- R46.81: Obsessive-compulsive behavior.
1 American Psychiatric Association’s Diagnostic and Statistical Manual, Fifth Edition (DSM-5)
- ICD-10-CM Expert, 2021. Optum
- Coding Clinic. Optum
- Mental illness in children. https://www.webmd.com/anxiety-panic/mental-health-illness-in-children
- Children’s Mental Health https://www.cdc.gov/childrensmentalhealth/symptoms.html
July 2021 Anthem Blue Cross Provider News - California