HEALTH INFORMATION MANAGEMENT: CODING ANXIETY

HEALTH INFORMATION MANAGEMENT: CODING ANXIETY

Anxiety is a normal and often healthy emotion. However, when a person regularly feels disproportionate levels of anxiety, it may become a medical disorder. Anxiety is often described as a feeling of worry, nervousness, or unease. Typically, these feelings occur when faced with an imminent event which is often an event with an uncertain outcome.

 Factors that put people at risk of an anxiety disorder are:

• Chemical imbalances
• Long-lasting stress
• Family history of anxiety
• Trauma
• Abuse of biological agents such as alcohol, drugs, or prescription medication.

Common medical conditions that may cause anxiety include asthma, diabetes, heart disease, hyperthyroidism, and hypothyroidism. Proper documentation of anxiety disorders is the key to capturing the patient’s condition in ICD-10-CM. Most often, the physician simply documents anxiety in the patient’s record. The U.S. Department of Health and Human Services recognizes five major types of anxiety disorders, and each have ICD-10-CM diagnosis codes.  

Generalized Anxiety Disorder (GAD)

GAD is an anxiety disorder characterized by chronic anxiety, exaggerated worry and tension.  This can be present even when there is little or nothing to provoke it. 

Obsessive-Compulsive Disorder (OCD)

OCD is an anxiety disorder that is characterized by recurrent, unwanted thoughts (obsessions) and/or repetitive behaviors (compulsions). Repetitive behaviors may include frequent hand washing, counting, checking, and cleaning.

Panic Disorder

Panic disorder is an anxiety disorder that is characterized by unexpected and repeated episodes of intense fear which can be accompanied by physical symptoms such as chest pain, heart palpitations, shortness of breath, or dizziness.

Post -Traumatic Stress Disorder (PTSD)

PTSD is an anxiety disorder that can develop after exposure to a terrifying event or ordeal.  These events often may involve grave physical harm which occurred or was threatened.  Traumatic events that may trigger PTSD include violent personal assaults, natural or human-caused disasters, accidents, or military combat. 

Social Phobia (or Social Anxiety Disorder)

Social Phobia, or Social Anxiety Disorder is an anxiety disorder that is characterized by overwhelming anxiety and excessive self-consciousness in everyday social situations.  It can be limited to only one type of situation such as fear of public speaking or fear of eating in front of others.  In its most severe form, this disorder may cause a person to experience symptoms anytime they are around other people.

A physical examination and a psychological evaluation are necessary to make a diagnosis of anxiety. Sequencing anxiety codes will depend on the circumstance of the admission and the physician’s documentation in the medical record. While anxiety appears normally in everyday life and is useful when alerting a person to danger, it can become concerning when it disrupts normal activities.

Cynthia Alder-Smith, RHIT CCS

Auditor/ Educator Excite Health Partners