Behavioral & Tip Sheet for ICD-10 Diagnosis Documentation Requirements

Document type: ADD and ADHD - Predominantly inattentive - Predominantly hyperactive - Combined type

Document type: Document type: Adjustment Disorder - Depressed mood - Disturbance of conduct - - Mixed disturbance of emotions - Mixed anxiety and depressed and conduct mood Differentiate between Dependence, document if in Document any substance Alcohol/ Drug Abuse alcohol/ remission which is based on induced disorders or dependence versus your clinical judgment complications: and Dependence -Do not document “use” as a - substitute for abuse or -

dependence - -Hallucinations

-Psychotic disorder Document current episode: Specify severity for manic Indicate status: - Hypomanic and depressed episodes: - Full remission - Manic - Mild - Partial remission - Depressed - Moderate - Mixed - Severe w/o psychotic symptoms - Severe with psychotic symptoms Document: Document: - Confined to family context - Adolescent-onset type - Childhood-onset type - Oppositional defiant

Document: Document underlying Document vascular - With behavioral disturbance condition (e.g. Alzheimer's, dementia as a result of - Without behavioral Parkinson's, Vit B deficiency) infarction disturbance Document type: - Major (see Major

Depression Depressive Disorder below) - Adjustment disorder with or without depression and/or anxiety, e.g., grief reaction - Anxiety depression

- Depressive Document: Document reason for Drug Underdosing - Intentional underdosing: versus - Financial hardship - Unintentional or - Age related dementia Specify type: Document Eating Disorders - Restricting type type: - Bulimia (Hyperorexia nervosa) - Binge eating/purging type - Atypical - Atypical

Version 1.0 Page 1

Behavioral & Mental Health Tip Sheet for ICD-10 Diagnosis Documentation Requirements

Document: Document etiology: If you’re intended or suspected Hepatic Failure/Hepatic -Acute/subacute -Due to alcohol or drugs diagnosis is hepatic failure/encephalopathy, -Chronic Encephalopathy document it in addition to signs -If with hepatic coma or symptoms, such as confusion, altered levels of consciousness, or coma. Specify: Document if due to Document any contribution Insomnia - Primary other from alcohol or drug use on - Adjustment condition, specify name of - Paradoxical List other underlying or related drug - Psychophysiological conditions: - Primary - - Insufficient sleep syndrome - Sleepwalking Document episode: Document severity: Indicate status: Major Depressive - Single - Mild - Full remission - Moderate - Partial remission Disorder - Recurrent - Severe w/o psychotic symptoms - Severe w/ psychotic symptoms Document type: Document severity: Document BMI Malnutrition - Protein-calorie - Mild or 1st degree - Protein-energy - Moderate or 2nd degree - Severe or 3rd degree Document type: Document etiology, cause and Pancreatitis - Acute effect: - Chronic - Idiopathic acute pancreatitis -Alcohol induced acute pancreatitis Document acuity: Post-traumatic - Acute - Chronic Disorder (PTSD)

Document type: Differentiate between: Document schizoaffective type: - Paranoid - Schizophrenia - Bipolar type - Disorganized - Schizotypal disorder - Depressive type - Catatonic - - Undifferentiated - - Residual - Shared psychotic disorder - Other Specify: Do NOT document 'use' for abuse Document any substance Substance Use, Abuse and - Use or dependence induced disorders or - Abuse complications Dependence - Dependence

Document type: Document state of dependence: Document if used during Tobacco Use Disorder - Cigarettes - In remission pregnancy, , - Chewing tobacco - With withdrawal puerperium - Other - Without withdrawal Describe history, including Delineate between: product and time - Tobacco use/abuse - Tobacco dependence

Version 1.0 Page 2