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Using the techniques described in this chapter carefully read through the case study and determine the most accurate ICD-10-CM code(s) and external cause code(s) if appropriate. Remember, check the chapter specific, sub-chapter specific and category specific notations within the Tabular list.

DATE OF ADMISSION: 11/15/2018
DATE OF DISCHARGE: 11/25/2018

DISCHARGE DIAGNOSES:

AXIS I:

1. Bipolar disorder, depressed, with psychotic features, symptoms in remission.
2. Attention deficit hyperactivity disorder, symptoms in remission.

AXIS II: Deferred.

AXIS III: None.

AXIS IV: Moderate.

AXIS V: Global assessment of functioning 65 on discharge.

REASON FOR ADMISSION: The patient was admitted with a chief complaint of suicidal ideation. The patient was brought to the hospital after his guidance counselor found a note the patient wrote, which detailed to whom he was giving away his possessions when he dies. The patient told the counselor that he hears voices telling him to hurt himself and others. The patient reports over the last month these symptoms have exacerbated. The patient had a fight in school recently, which the patient blames on the voices. Three weeks ago, he got pushed into a corner at school and threatened to shoot himself and others with a gun. The patient was suspended for that remark.

PROCEDURES AND TREATMENT:

1. Individual and group psychotherapy.
2. Psychopharmacologic management.
3. Family therapy with the patient and the patient’s family for the purpose of education and discharge planning.

HOSPITAL COURSE: The patient responded well to individual and group psychotherapy, milieu therapy, and medication management. As stated, family therapy was conducted.

DISCHARGE ASSESSMENT: At the time of discharge, the patient is alert and fully oriented. Mood euthymic. Affect broad range. He denies any suicidal or homicidal ideation. IQ is at baseline. Memory intact. Insight and judgment good.

PLAN: The patient may be discharged as he no longer poses a risk of harm towards himself or others.

The patient will continue on the following medications: Ritalin LA 60 mg q.a.m., Depakote 500 mg q.a.m. and 750 mg q.h.s., Abilify 20 mg q.h.s. Depakote level on date of discharge was 110. Liver enzymes drawn were within normal limits.

The patient will follow up with Dr. Wallace for medication management and Dr. Deiter for psychotherapy. All other discharge orders per the psychiatrist, as arranged by social work.

Be sure to list the codes, one code per box, in the correct order, from top to bottom. Capitalization, punctuation, and spacing can impact whether or not your answer is correct. Follow coding best practices.

What is/are the correct diagnosis code(s)?

Answer 1

Answer: Codes are used to classify the diagnosis so that it can be used for further reimbursement. The ICD 10CM codes for the following are: • • Bipolar disorder, depressed, with psychotic features, symptoms in remission. - F31.2 Attention Deficit hyperactivity disorder impulsive type - F 90.1 F31.9 - bipolar disorder, depressed with symptoms of remission • F01-F99 -Mental, Behavioral and Neurodevelopmental disorder F30-F39 mood disorders F31- Bipolar disorder • F31.9 - Bipolar disorder, depressed with symptoms of remission F90.1-Attention Deficit hyperactivity disorder impulsive type F01-F99- Mental, Behavioral and Neurodevelopmental disorder F90-F98- Behavioral and emotional disorders with onset usually occurring in childhood and adolescence F90- Attention deficit hyperactivity disorder F90.1- attention deficit hyperactivity disorder, impulsive presentation.