F02.B11

ICD-10-CM Official Guidelines for Coding and Reporting, quoted in full. Published by CMS and NCHS; in the public domain.

I.A.13 Etiology/manifestation convention (“code first”, “use additional names this code p.10

code” and “in diseases classified elsewhere” notes) Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD-10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, followed by the manifestation. Wherever such a combination exists, there is a “use additional code” note at the etiology code, and a “code first” note at the manifestation code. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation. In most cases the manifestation codes will have in the code title, “in diseases classified elsewhere.” Codes with this title are a component of the etiology/ manifestation convention. The code title indicates that it is a manifestation code. “In diseases classified elsewhere” codes are never permitted to be used as first listed or principal diagnosis codes. They must be used in conjunction with an underlying condition code and they must be listed following the underlying condition. See category F02, Dementia in other diseases classified elsewhere, for an example of this convention. There are manifestation codes that do not have “in diseases classified elsewhere” in the title. For such codes, there is a “use additional code” note at the etiology code and a “code first” note at the manifestation code, and the rules for sequencing apply. In addition to the notes in the Tabular List, these conditions also have a specific Alphabetic Index entry structure. In the Alphabetic Index both conditions are listed together with the etiology code first followed by the manifestation codes in brackets. The code in brackets is always to be sequenced second. An example of the etiology/manifestation convention is dementia with Parkinson’s disease. In the Alphabetic Index, a code from category G20 is listed first, followed by code F02.80 or F02.81- in brackets. A code from category G20- represents the underlying etiology, Parkinson’s disease, and must be sequenced first, whereas codes F02.80 and F02.81- represent the manifestation of dementia in diseases classified elsewhere, with or without behavioral disturbance. “Code first” and “Use additional code” notes are also used as sequencing rules in the classification for certain codes that are not part of an etiology/ manifestation combination. See Section I.B.7. Multiple coding for a single condition.

I.C.5 Chapter 5: Mental, Behavioral and Neurodevelopmental disorders names this code p.43

(F01 – F99)

I.C.5.d Dementia names this code p.45

The ICD-10-CM classifies dementia (categories F01, F02, and F03) on the basis of the etiology and severity (unspecified, mild, moderate or severe). Selection of the appropriate severity level requires the provider’s clinical judgment and codes should be assigned only on the basis of provider documentation (as defined in the Official Guidelines for Coding and Reporting), unless otherwise instructed by the classification. If the documentation does not provide information about the severity of the dementia, assign the appropriate code for unspecified severity. If a patient is admitted to an inpatient acute care hospital or other inpatient facility setting with dementia at one severity level and it progresses to a higher severity level, assign one code for the highest severity level reported during the stay.

I.C.5.a Pain disorders related to psychological factors chapter guidance p.43

Assign code F45.41, for pain that is exclusively related to psychological disorders. As indicated by the Excludes 1 note under category G89, a code from category G89 should not be assigned with code F45.41. Code F45.42, Pain disorders with related psychological factors, should be used with a code from category G89, Pain, not elsewhere classified, if there is documentation of a psychological component for a patient with acute or chronic pain. See Section I.C.6. Pain

I.C.5.b Mental and behavioral disorders due to psychoactive substance chapter guidance p.43

use

I.C.5.b.1 In Remission chapter guidance p.43

Selection of codes describing “in remission” for categories F10-F19, Mental and behavioral disorders due to psychoactive substance use (categories F10-F19 with -.11, -.21, -.91) requires the provider’s clinical judgment and are assigned only on the basis of provider documentation (as defined in the Official Guidelines for Coding and Reporting), unless otherwise instructed by the classification. Mild substance use disorders in early or sustained remission are classified to the appropriate codes for substance abuse in remission, and moderate or severe substance use disorders in early or sustained remission are classified to the appropriate codes for substance dependence in remission.

I.C.5.b.2 Psychoactive Substance Use, Abuse and Dependence chapter guidance p.43

When the provider documentation refers to use, abuse and dependence of the same substance (e.g. alcohol, opioid, cannabis, etc.), only one code should be assigned to identify the pattern of use based on the following hierarchy: • If both use and abuse are documented, assign only the code for abuse • If both abuse and dependence are documented, assign only the code for dependence • If use, abuse and dependence are all documented, assign only the code for dependence • If both use and dependence are documented, assign only the code for dependence.

I.C.5.b.3 Psychoactive Substance Use, Unspecified chapter guidance p.44

As with all other unspecified diagnoses, the codes for unspecified psychoactive substance use (F10.9-, F11.9-, F12.9-, F13.9-, F14.9-, F15.9-, F16.9-, F18.9-, F19.9-) should only be assigned based on provider documentation and when they meet the definition of a reportable diagnosis (see Section III, Reporting Additional Diagnoses). These codes are to be used only when the psychoactive substance use is associated with a substance related disorder (chapter 5 disorders such as sexual dysfunction, sleep disorder, or a mental or behavioral disorder) or medical condition, and such a relationship is documented by the provider.

I.C.5.b.4 Medical Conditions Due to Psychoactive Substance Use, Abuse chapter guidance p.44

and Dependence Medical conditions due to substance use, abuse, and dependence are not classified as substance-induced disorders. Assign the diagnosis code for the medical condition as directed by the Alphabetical Index along with the appropriate psychoactive substance use, abuse or dependence code. For example, for alcoholic pancreatitis due to alcohol dependence, assign the appropriate code from subcategory K85.2, Alcohol induced acute pancreatitis, and the appropriate code from subcategory F10.2, such as code F10.20, Alcohol dependence, uncomplicated. It would not be appropriate to assign code F10.288, Alcohol dependence with other alcohol-induced disorder.

I.C.5.b.5 Blood Alcohol Level chapter guidance p.44

A code from category Y90, Evidence of alcohol involvement determined by blood alcohol level, may be assigned when this information is documented and the patient’s provider has documented a condition classifiable to category F10, Alcohol related disorders. The blood alcohol level does not need to be documented by the patient’s provider in order for it to be coded. See Section I.B.14. for blood alcohol level documentation by clinicians other than patient's provider.

I.C.5.c Factitious Disorder chapter guidance p.44

Factitious disorder imposed on self or Munchausen’s syndrome is a disorder in which a person falsely reports or causes his or her own physical or psychological signs or symptoms. For patients with documented factitious disorder on self or Munchausen’s syndrome, assign the appropriate code from subcategory F68.1-, Factitious disorder imposed on self. Munchausen’s syndrome by proxy (MSBP) is a disorder in which a caregiver (perpetrator) falsely reports or causes an illness or injury in another person (victim) under his or her care, such as a child, an elderly adult, or a person who has a disability. The condition is also referred to as “factitious disorder imposed on another” or “factitious disorder by proxy.” The perpetrator, not the victim, receives this diagnosis. Assign code F68.A, Factitious disorder imposed on another, to the perpetrator’s record. For the victim of a patient suffering from MSBP, assign the appropriate code from categories T74, Adult and child abuse, neglect and other maltreatment, confirmed, or T76, Adult and child abuse, neglect and other maltreatment, suspected. See Section I.C.19.f. Adult and child abuse, neglect and other maltreatment

Risk adjustment

This code