Tips for Accurate Code Assignment of Other specified vs Unspecified Schizophrenia Spectrum Disorder

Jennifer Jones, RHIT, CCS, CCDS Medical Coding Leave a Comment

Tips for Accurate Code Assignment of Other specified vs Unspecified Schizophrenia Spectrum Disorder

Coding diagnoses from ICD-10-CM, Chapter 5: Mental, Behavioral and Neurodevelopmental Disorders, does not prove to be an easy task. Psychiatry and mental health professionals use the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) for applying diagnoses, which does not always correspond equally to codes from ICD-10-CM, and it is up to the coder to evaluate the documentation and apply the correct ICD-10-CM code, and knowing the background according to DSM-5 is helpful.

To code the diagnosis of Schizophrenia Spectrum Disorder, consult the index and start with the key word “disorder”, followed by “schizophrenia spectrum and other psychotic disorder”. There are two options, F28 and F29.

 JJ schizo table

In regards to code F28, the tabular lists the description as “other psychotic disorder not due to a substance or known physiologic condition”. Per DSM-5 this category applies to presentations in which symptoms characteristic of a schizophrenia spectrum and other psychotic disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the schizophrenia spectrum and other psychotic disorders class. This diagnosis is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any specific schizophrenia spectrum and other psychotic disorder. This is done by recording “Other Specified Schizophrenia Spectrum and Other Psychotic Disorder” followed by the specific reason (e.g., persistent auditory hallucinations).

Examples that can be specified using the “other specified” designation include the following:

  1. Persistent auditory hallucinations
  2. Delusions with significant overlapping mood episodes
  3. Attenuated psychosis syndrome
  4. Delusional symptoms in a partner of individual with delusional disorder

Note: In ICD-10-CM, there is no edit to use additional code for the specific reason, and there is no Excludes1 or 2 with code F28. This code includes chronic hallucinatory psychosis and other specified schizophrenia spectrum and other psychotic disorder.

In regards to code F29, the tabular lists the description as “unspecified psychosis not due to a substance or known physiologic condition”. Per DSM-5 this category applies to presentations in which symptoms characteristic of a schizophrenia spectrum and other psychotic disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the schizophrenia spectrum and other psychotic disorders diagnostic class. The unspecified schizophrenia spectrum and other psychotic disorder category is used in situations in which the clinician chooses not to specify the reason that the criteria are not met for a specific schizophrenia spectrum and other psychotic disorder, and includes presentations in which there is insufficient information to make a more specific diagnosis (e.g., in emergency room settings).

Note: In ICD-10-CM, there is an Excludes1 for mental disorder NOS (F99) and unspecified mental disorder due to known physiologic condition (F09).

 

In summary, it is necessary to make sure the ICD-10-CM code assignment matches provider documentation - is it “other” or is it “unspecified” schizophrenia spectrum disorder? One word makes a difference in appropriate coding of this diagnosis.

References: 2020 ICD-10-CM Expert, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)

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