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Documenting Mental and Behavioral Health Issues with ICD-10 Codes

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Mental health disorders may include biological and neurological issues and affect a person’s mood and thinking. Behavioral health issues result from one’s conscious decisions and which one is unable to resist despite negative consequences.

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Documenting Mental and Behavioral Health Issues with ICD-10 Codes

  1. 1. www.outsourcestrategies.com 1-800-670-2809 Documenting MENTAL & BEHAVIORAL Health Issues with ICD-10 Codes Mental health disorders may include biological and neurological issues and affect a person’s mood and thinking. Behavioral health issues result from one’s conscious decisions and which one is unable to resist despite negative consequences. 2018
  2. 2. www.outsourcestrategies.com 1-800-670-2809 A mental health disorder refers to a wide range of mental health conditions – that are often biological and include neurological issues a person is actually born with and that affect their mood, thinking and behavior. A mental health concern becomes an illness when the ongoing signs and symptoms cause frequent stress and affect your ability to function. These include - anxiety disorders, phobias, addiction, bipolar disorders, depression and other personality disorders. In addition, chronic illness can play a role in mental disorders due to the stress created by the condition. On the other hand, behavioral health refers to a person’s “state of mental/emotional being and how their choices and actions affect their overall health and wellness. Substance abuse or misuse, alcohol and drug addiction, serious psychological distress, suicide and other mood disorders fall under the category of behavioral health issues. Disorders listed under this group tend to fall under the personal decisions an individual makes or decisions others make that affect someone else. According to reports from the Medicare Expenditure Panel Survey (MEPS), mental disorders contribute to about 65 million physician visits and over 5 million emergency department (as a primary diagnosis) visits annually. Medical coding for mental and behavioral health disorders is very complex and for accurate clinical documentation of these conditions, physicians depend on the services of medical billing outsourcing companies. How Is Behavioral Health Different from Mental Health Disorders? Although behavioral health and mental health tend to overlap, distinct differences exist between the two. The U.S. Department of Health and Human Services defines mental health as a person’s psychological, emotional, and social wellbeing. However, some mental health issues may be impacted by behavior, many health disorders have neurological or biological causes, meaning simply changing a person’s behavior may not cure them of that illness.
  3. 3. www.outsourcestrategies.com 1-800-670-2809 Signs and Symptoms Both behavioral health and mental health disorders can cause serious problems in daily life. The initial signs and symptoms of these disorders can vary, depending on the disorder, circumstances and other factors. In most cases, symptoms can be effectively managed through a combination of medications and psychotherapy. Some of the prominent symptoms include – Mental Health Disorder • Alcohol or drug abuse • Confused thinking or reduced ability to concentrate • Excessive fears or worries, or extreme feelings of guilt • Extreme mood changes of highs and lows • Inability to cope with daily problems or stress • Major changes in eating habits • Significant tiredness, low energy or problems sleeping • Suicidal thinking • Withdrawal from friends and activities In addition, some symptoms appear as physical problems, such as stomach pain, back pain, headache, or other unexplained aches and pains. Behavioral Health Disorder • Revenge-seeking behaviors • Physical abuse of others • Lying and stealing things • Lack of problem-solving skills • Deliberately annoys other people • Blames others for his/her mistakes • Antisocial behaviors • Anger
  4. 4. www.outsourcestrategies.com 1-800-670-2809 • Actively defies or refuses to comply with requests or rules Diagnosis and Documentation In most cases, diagnosing these mental and behavioral health conditions is quite difficult as the symptoms may mimic those of other conditions. But taking the time and effort to get an accurate diagnosis will help determine the appropriate treatment. Initial diagnosis involves – physical exam (to determine physical problems that could cause your symptoms), lab tests and a detailed psychological evaluation. The mode of treatment may depend on the severity of illness. In most cases, a combination of treatments involving medications (such as antidepressants, antipsychotic and mood-stabilizing medications), psychotherapy, brain stimulation treatments, substance abuse treatment, Cognitive behavioral therapy (CBT), motivational interviewing and reality therapy are offered. Documentation for these disorders must include - the type of condition, the status and exact causes - like any complications or manifestations and any co-morbid conditions as well. Psychologists/psychoanalysts who treat these mental or behavioral disorders rely on reputable medical billing companies to code the condition accurately. The following ICD-10 codes are to be used on the medical claims for these mental and behavioral conditions - • F01-F09 - Mental disorders due to known physiological conditions • F10-F19 - Mental and behavioral disorders due to psychoactive substance use • F20-F29 - Schizophrenia, schizotypal, delusional, and other non-mood psychotic disorders • F30-F39 - Mood [affective] disorders • F40-F48 - Anxiety, dissociative, stress-related, somatoform and other non-psychotic mental disorders
  5. 5. www.outsourcestrategies.com 1-800-670-2809 • 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 Medical billing and coding of these mental and behavioral disorders can be a tricky process. Therefore, learning the nuances can help achieve accurate coding, which is important from the point of patient care as well as reimbursement.

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