This post was originally published on September 28, 2018, and updated on January 24, 2020.
Coding for post-traumatic stress disorder should not cause too much anxiety once you know these 3 things:
- Know what to look for in the documentation, such as whether the condition is acute or chronic.
- Know how to find the correct code in the ICD-10-CM coding manual.
- Have an understanding of the coding guidelines as they apply to symptoms that are integral to the disease process.
Now let’s use this information to code the following coding exercise.
Question: A 16-year-old female patient is seen today with complaints of severe anxiety, anger, flashbacks, and difficulty sleeping that has lasted four months. Patient was previously seen in the emergency room after sustaining a gunshot wound to the left shoulder. Following examination, the patient is diagnosed with post-traumatic stress disorder (PTSD).
Assign the ICD-10-CM code for the PTSD.
F43.10,Post-traumatic stress disorder, unspecified
Post-traumatic stress disorder (PTSD) is reported with ICD-10-CM codes from Chapter 5. Mental, Behavioral and Neurodevelopmental disorders (F01-F99), section F40-F48, Anxiety, dissociative, stress-related, somatoform and other nonpsychotic mental disorders, category F43, Reaction to severe stress, and adjustment disorders.
The ICD-10-CM codes for PTSD are located in subcategory F43.1, Post-traumatic stress disorder and include:
- F43.10, Post-traumatic stress disorder, unspecified
- F43.11, Post-traumatic stress disorder, acute
- F43.12, Post-traumatic stress disorder, chronic
Locate and Verify
Looking in the ICD-10-CM coding manual Index, see Disorder (of), post-traumatic stress (PTSD) F43.10.
This code can be verified in the Tabular as F43.10 Post-traumatic stress disorder, unspecified.
The documentation does not specify if the PTSD is acute or chronic, so we need to go with the unspecified code.
We can now check off #1. Know what to look for in the documentation, such as whether the condition is acute or chronic.
We can also check off #2. Know how to find the correct code in the ICD-10-CM coding manual.
There is a subterm listed at F43.1. It is “traumatic neurosis.” Therefore, if the documentation indicates the diagnosis is traumatic neurosis or PTSD, F43.1 would be the code to assign.
See the instructional notes at F01-F99 that states:
Includes: disorders of psychological development
Excludes2: symptoms, signs and abnormal clinical laboratory findings, not elsewhere classified (R00-R99)
Based on the coding guidelines, there is no need to assign for the symptoms here, because anxiety, anger, flashbacks, and difficulty sleeping are all symptoms of PTSD
According to the ICD-10-CM Coding Guidelines:
“Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes unless otherwise instructed by the classification.”
We can now check off #3. Have an understanding of the coding guidelines as they apply to symptoms that are integral to the disease process.
What is Post-Traumatic Stress Disorder?
According to the American Psychiatric Association, “Post-traumatic stress disorder (PTSD) is a psychiatric disorder that can occur in people who have experienced or witnessed a traumatic event such as a natural disaster, a serious accident, a terrorist act, war/combat, rape or other violent personal assault.”
Several of the following symptoms occur in PTSD and can vary in severity:
- Repeated, involuntary memories
- Distressing dreams
- Flashbacks of the event
- Avoidance of certain people, places, activities, objects, and situations
- Distorted beliefs about oneself
- Inability to recall parts of the event
- Constant fear, horror, anger, guilt, or shame
- Feeling of detachment
- Acting out in a self-destructive manner
- Easily startled
- Trouble concentrating or sleeping
Symptoms of PTSD often occur within three months of a traumatic event, but they may appear later. For a person to be diagnosed with PTSD, the symptoms must last for more than a month, and many times they persist for months or even years.
Not everyone who experiences trauma develops PSTD and not everyone who experiences either needs psychiatric treatment. Sometimes the symptoms will eventually disappear. Other times, the distress can be so severe that professional treatment is needed. Such treatment as psychotherapy (talk therapy) and medication have proven effective for PTSD.