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, unspecifiedPost-traumatic stress disorder (PTSD) is reported with ICD-10-CM codes from Chapter 5. Mental, Behavioral and Neurodevelopmental disorders (F01-F99), block F40-F48 Anxiety, dissociative, stress-related, somatoform and other nonpsychotic mental disorders.
The ICD-10 reportable codes for PTSD include:
- F43.10, post-traumatic stress disorder, unspecified
- F43.11, post-traumatic stress disorder, acute
- F43.12, post-traumatic stress disorder, chronic
Looking in the ICD-10-CM coding manual, see Disorder, stress, post-traumatic F43.10. This can be verified in the Tabular as F43.10 Post-traumatic stress disorder, unspecified.
According to the ICD-10-CM Coding Guidelines:
“A code listed next to a main term in the ICD-10-CM Alphabetic Index is referred to as a default code. The default code represents that condition that is most commonly associated with the main term, or is the unspecified code for the condition. If a condition is documented in a medical record (for example, appendicitis) without any additional information, such as acute or chronic, the default code should be assigned.”
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.”
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.
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