Chapter 9 Flashcards
behavioral disturbance
a type of common behavior that includes mood disorders (such as depression, apathy, and euphoria), sleep disorders (such as insomnia and hypersomnia), psychotic symptoms (such as delusions and hallucinations), and agitation (such as pacing, wandering and aggression)
sedative
a tranquilizer, a drug used to calm or soothe
hypnotic
a drug that induces sleep
anxiolytic
a drug used to reduce anxiety
use
occasional consumption of a substance without clinical manifestations
abuse
regular consumption of a substance with manifestations
depedndence
ongoing, regular consumption of a substance with resulting significant clinical manifestations and a dramatic decrease in the effect of the substance with continued used, therefore requiring an increased quantity of the substance to achieve intoxication
anxiety
the feeling of apprehension and fear, sometimes manifested with physical manifestations such as sweating and palpitations
manic
an emotional state that includes elation, excitement, and exuberance
depressive
an emotional state that includes sadness hopelessness and gloom
schizophrenia
a psychotic disorder with no known cause
phobia
irrational and excessive fear of an object, activity, or situation
examples
F40.0 Agoraphobia
F40.1 Social phobia
F40.23 Blood, injection, injury type phobia
F41.0 Panic disorder (episodic paroxysmal anxiety)
F41.1 Generalized anxiety disorder
somatoform disorder
the sincere belief that one is suffering an illness that is not present
F45.0 Somatization disorder (Multiple psychosomatic disorder)
F45.22 Body dysmorphic disorder
F45.41 Pain disorder exclusively related to psychological factors
F45.42 Pain disorder with related psychological factors
acute
severe, serious
chronic
long duration, continuing over an extended period of time
Pain is an inclusive symptom except when
the principle purpose of the encounter is pain management and the encounter does not include treatment or management of the underlying condition
the pain is noted as acute and or chronic, documenting that the pain suffered by the patient is above and beyond the level typical of the underlying condition
A mental disorder can be caused by a…?
physiological condition
examples-
an infarction of the brain
hypertensive
cerebrovascular disease
a disease such as Creutzfeldt-Jakob disease, Parkinson’s disease, or trypanosomiasis
an endocrine disorder, exogenous hormone, or toxic substance that can cause cognitive and/or intellectual malfunction
Provide Examples of Mood (Affective) Disorders
Bipolar disorders
Major depressive disorders
Do Bipolar disorder codes change frequently for each patient? Why?
yes. they may or may not experience psychotic features. those features may be mild to moderate
What happens when someone has Catatonic (schizophrenic catalepsy, catatonia, or flexibilitas cerea)?
they cannot move,.
What are the five different types of schizophrenia?
paranoid (paraphrenic schizophrenia) F20.0
Disorganized (hebephrenic schizophrenia or hebephrenia) F20.1
Catatonic (schizophrenic catalepsy, catatonia, or flexibilitas cerea)? F20.2
Undifferentiated (atypical schizophrenia) F20.3
residual (restzustand) F20.5
Schizoid Personality Disorder
patient exhibit a limited range of emotions and an aversion to social relationships and personal interactions, and have a flat affect
F60.1 Schizoid personality disorder
Excludes 1 note
never code with
Excludes 2 note
you can code with another code
Panic disorder is also?
Panic attack
Both coded
F41.0
Post-traumatic stress disorder (P T S D)
a condition in which a horrible experience leaves a lasting imprint on the patient’s sense of danger
(look for unspecified, acute, or chronic when coding)
When Reporting PTSD, remember to include external cause codes to explain the specifics about the traumatic event
Examples
F43.10 PTSD, unspecified
F43.11 PTSD, acute
F43.12 PTSD, chronic
Inflammatory Conditions of the CNS
G00.1 Pneumoccoccal meningitis
G00.8 Other bacterial meningitis (Meningitis due to Escherichia coli)
G03.0 Nonpyogenic meningitis
Hereditary and Degenerative Diseases of the CNS
G31.01 Frontotemporal dementia (Pick’s disease)
G31.83 Dementia with Lewy bodies (Lewy body dementia)
communicating hydrocephalus (secondary normal pressure hydrocephalus)
CODE
G91.0 Communicating hydrocephalus
Noncommunicating hydrocephalus (obstructive hydrocephalus)
CODE
G91.1 Obstructive hydrocephalus
(Idiopathic) normal pressure hydrocephalus (N P H)- we don’t know what causes it
CODE
G91.2 (Idiopathic) Normal pressure hydrocephalus
Post-traumatic hydrocephalus ex-vacuo)
CODE
G91.3 Post-traumatic hydrocephalus, unspecified
Hydrocephalus may also occur as a manifestation of another condition, such as a neoplasm or congenital syphilis
CODE
G91.4 Hydrocephalus in diseases classified elsewhere
What details are required to code a Migraine Accurately?
Code category G43 Migraine
Is it a(n)
Aura Intractable Status migrainosus chronic other types of migraines
Dominant Sides
Physiological Conditions Affecting the Peripheral Nervous System
if the documentation states the right side is affected–report as dominant
Nondominant Sides
Physiological Conditions Affecting the Peripheral Nervous System
If the documentation states the left side is affected–report as nondominant
Ambidextrous
Physiological Conditions Affecting the Peripheral Nervous System
whichever side is documented as affected should be reported as the patient’s dominant side
Carpal Tunnel Syndrome
Condition that causes numbness, tingling, or weakness in your hand. It happens because of pressure on your median nerve, which runs the length of your arm, goes through a passage in your wrist called the carpal tunnel, and ends in your hand.
G56.01 Carpel tunnel syndrome, right upper limb or
G56.02 Carpel tunnel syndrome, left upper limb
or
G56.03 Carpel tunnel syndrome, bilateral upper limbs
Plexus Disorders
many plexus disorders are the result of a specific point in the peripheral neural pathway for that plexus becoming compressed
G54.0 Brachial plexus disorders
or
G54.1 Lumbosacral plexus disorders
CRPS-I (reflex sympathetic dystrophy syndrome)
{Complex Regional Pain Syndrome (CRPS)}
patient denies the occurrence of any nerve injury
Examples
G90.511 Complex regional pain syndrome I of right upper limb
G90.512 Complex regional pain syndrome I of left upper limb
CRPS- II (causaligia)
{Complex Regional Pain Syndrome (CRPS)}
with a confirmed nerve injury prior to diagnosis
examples
G57.71 Causalgia of right lower limb
G57.72 Causalgia of left lower limb
Numeric Pain Scale
0- No pain
1-3 Mild pain (nagging, annoying, interfering little with A D L s)
4-6 Moderate pain (interferes significantly with A D L s)
7-10 Severe pain (Disabling, unable to perform A D L s)
ADLs
activities of daily living
Pain is considered to be an inclusive symptom, EXCEPT when
- the principal purpose of the encounter is pain management and the encounter does not include treatment or management of the underlying condition
- the pain is noted as acute and or chronic, documenting that the pain suffered by the patient is above and beyond the level typical of the underlying
Report from code category G89 Pain, not elsewhere classified
Postprocedural Pain
G89.18 Other acute postprocedural pain (postprocedural pain N O S)
G89.28 Other chronic postprocedural pain
One of these codes may be reported only when the pain is documented as:
- more intense or lasting longer than the expected level of pain that is considered normal immediately after a surgical procedure
- not related to a detailed complication of the surgical procedure
Site- Specific Pain Codes
there are several code categories used to report pain located in a specific anatomical site.
Code category G89 Pain, not elsewhere classified, does not include any site- specific information. Anatomical site- specific code categories include:
M54.5 Low back pain lumbago)
M79.602 Pain in the left arm
M79.672 Pain in the left foot
Sequencing Pain Codes with Other Codes
The first question to be answered from the documentation is, “Why was this encounter necessary?”
If the answer is for PAIN MANAGEMENT, the code from category G89 should be first-listed or the principal diagnosis reported.
If the encounter is for ANY OTHER REASON and the attention to pain management is secondary to the purpose for the encounter, then the first-listed or principle diagnosis code would report that other reason and the code from category G89 would be reported afterward.
