This document provides guidelines for coding mental, behavioral and neurodevelopmental disorders using ICD-10-CM codes. It outlines the different blocks of codes in Chapter 5 including codes for mental disorders due to known physiological conditions, alcohol and substance abuse disorders, schizophrenia and other psychotic disorders, mood disorders, anxiety disorders and more. It provides examples of how to apply codes based on documentation of conditions like pain disorders, substance use, abuse and dependence, and factitious disorder.
2. Chapter 5 contains the following blocks:
• F01-F09 Mental disorders due to known physiological conditions
• F10-F19 Alcohol dependence and abuse
• F20-F29 Schizophrenia, delusional, and other non mood psychotic disorders
• F30-F39 Mood affective disorders
• F40-F48 Anxiety, dissociative, stress related, somatoform and other nonpsychotic mental
disorders
• F50-F59 Behavioral syndromes associated with physiological disturbances and physical
factors
• F60-F69 Disorders of adult personality and behavior
• F70-F79 Intellectual disabilities
• F80-F89 Pervasive and specific developmental disorders
• F90-F98 Behavioral and emotional disorders with onset usually occurring in childhood and
adolescence
• F99 Unspecified mental disorder
3. Chapter 5 Guidelines
a. Pain disorders related to psychological factors
b. Mental and behavioral disorders due to psychoactive substance
1. In remission
2. Psychoactive Substance Use, Abuse and Dependence
3. Psychoactive use unspecified
c. Factitious disorder
4. CG I.C.5.a.
• a. Pain disorders related to psychological factors
• Assign code F45.41, for pain that is exclusively related to psychological disorders.
As indicated by the Excludes 1 note under category G89, a code from category
G89 should not be assigned with code F45.41.
• Code F45.42, Pain disorders with related psychological factors, should be used
with a code from category G89, Pain, not elsewhere classified, if there is
documentation of a psychological component for a patient with acute or chronic
pain.
5. CG I.C.5.a.
Scenario Code Index Pathway/Guideline
Patient suffered recurrent back pain.
Diagnostic test were performed with
negative results. Physician documents
final diagnosis chronic psychogenic pain.
F45.41 Pain, Psychogenic (persistent) any site F45.41
ICD-10-CM Coding Guideline: Assign code F45.41, for pain that is
exclusively related to psychological disorders. As indicated by the
Excludes 1 note under category G89, a code from category G89
should not be assigned with code F45.41.
CG 1.C.5.a.
6. CG I.C.5.a.
Scenario Code Index Pathway/Guideline
Mr. Al was seen by his physician
complaining of chronic back pain
from an injury he suffered a year
ago. Mr. Al informed his Dr. He has
not been feeling like himself
somewhat depressed since his
injury. The physician prescribes
medication for the pain and
recommends Mr. Al see a
psychologist for depression
secondary to chronic back pain due
to trauma.
G89.21
F45.42
F32.9
M54.9
Pain, chronic , due to trauma
Disorder, pain, with related psychological factors
Depression, unspecified
Pain, back
ICD-10-CM Coding Guideline: Pain disorders related to psychological factors
Code F45.42, Pain disorders with related psychological factors, should
be used with a code from category G89, Pain, not elsewhere classified, if
there is documentation of a psychological component for a patient with
acute or chronic pain.
See Section I.C.6. Pain
CG 1.C.5.a.
7. CG I.C.5.b.1
Scenario Code Index Pathway/Guideline
Patient has a history of cocaine
abuse, lab results indicate no
current drug use. Physician
documents cocaine abuse in
remission.
F14.21 History, personal, drug dependence, ( Instructional note, see dependence, drug by
type in remission)
ICD-10-CM Coding Guideline: In Remission
Selection of codes for “in remission” for categories F10-F19, Mental and
behavioral disorders due to psychoactive substance use (categories F10-
F19 with -.11, -.21) requires the provider’s clinical judgment. The
appropriate codes for “in remission” are assigned only on the basis of
provider documentation (as defined in the Official Guidelines for Coding
and Reporting), unless otherwise instructed by the classification.
Mild substance use disorders in early or sustained remission are classified
to the appropriate codes for substance abuse in remission, and moderate
or severe substance use disorders in early or sustained remission are
classified to the appropriate codes for substance dependence in
remission.
CG I.C.5.b.1
8. CG I.C.5.b.2
Scenario Code Index Pathway/Guideline
Alcohol dependence with
Intoxication
Alcohol abuse with use of cannabis
Chronic alcohol abuse with
dependence
Cannabis use with anxiety disorder
due to cannabis abuse
F10.229
F10.10
F12.90
F10.20
F12.180
Intoxication, alcoholic ( follow instructional notes)
Abuse, alcohol
Use, Cannabis
Dependence, alcohol ( without remission)
Abuse, drug cannabis with anxiety disorder
ICD-10-CM Coding Guideline: Psychoactive Substance
When the provider documentation refers to use, abuse and dependence of the
same substance (e.g. alcohol, opioid, cannabis, etc.), only one code should be
assigned to identify the pattern of use based on the following hierarchy:
• If both use and abuse are documented, assign only the code for abuse
• If both abuse and dependence are documented, assign only the code for
dependence
• If use, abuse and dependence are all documented, assign only the code for
dependence
• If both use and dependence are documented, assign only the code for
dependence.
9. CG I.C.5.b.2.
Scenario Code Index Pathway/Guideline
Patient presented for for treatment
for alcohol abuse with mood
disorder. Blood alcohol level test
results were 28mg/100ml
Joel presents to ER a known cocaine
abuser with signs of tremors and
withdrawal
F10.14
Y90.1
F14.23
Abuse, alcohol ( see instructional notes)
Blood alcohol level
Withdrawal ( see instruction note see also dependence by drug type with
withdrawal)
CG I.C.5.b.2
10. CG I.C.5.b.3
Scenario Code Index Pathway/Guideline
Joan a college student used an
unspecified stimulant for anxiety
disorder.
F15.90 Use, Stimulant
ICD-10-CM Coding Guideline: Psychoactive substance use (unspecified)
As with all other unspecified diagnoses, the codes for unspecified
psychoactive substance use (F10.9-, F11.9-, F12.9-, F13.9-, F14.9-, F15.9-,
F16.9-, F18.9-, F19.9-) should only be assigned based on provider
documentation and when they meet the definition of a reportable
diagnosis (see Section III, Reporting Additional Diagnoses). These codes are
to be used only when the psychoactive substance use is associated with a
physical, mental or behavioral disorder, and such a relationship is
documented by the provider.
CG I.C.5.b.3
11. CG I.C.5.c.
Scenario Code Index Pathway/Guideline
Patient presented to the ED
stating he had taken a large
volume of pills and needed his
stomach pumped, however after
having his stomach pumped pills
were not located. Physician final
diagnosis Factitious disorder
F68.10 Disorder, Factitious
ICD-10-CM Coding Guideline: Factitious Disorder
Factitious disorder imposed on self or Munchausen’s syndrome is a disorder in which
a person falsely reports or causes his or her own physical or psychological signs or
symptoms. For patients with documented factitious disorder on self or Munchausen’s
syndrome, assign the appropriate code from subcategory F68.1-, Factitious disorder
imposed on self.
Munchausen’s syndrome by proxy (MSBP) is a disorder in which a caregiver
(perpetrator) falsely reports or causes an illness or injury in another person (victim)
under his or her care, such as a child, an elderly adult, or a person who has a disability.
The condition is also referred to as “factitious disorder imposed on another” or
“factitious disorder by proxy.” The perpetrator, not the victim, receives this diagnosis.
Assign code F68.A, Factitious disorder imposed on another, to the perpetrator’s
record. For the victim of a patient suffering from MSBP, assign the appropriate code
from categories T74, Adult and child abuse, neglect and other maltreatment,
confirmed, or T76, Adult and child abuse, neglect and other maltreatment, suspected.
See Section I.C.19.f. Adult and child abuse, neglect and other maltreatment.
CG I.C.5.c.
