The impact of the opioid crisis is felt in each and every part of the healthcare system. To help continue the battle against this national epidemic, coding and documentation professionals were given more tools to fight the opioid crisis with ICD-10-CM and subsequent code updates.
Along with the bolstered response to the opioid epidemic, recent updates to the Diagnostic and Statistical Manual of Mental Health Disorders, and an increased focus on the population growth of Americans with dementia, mental health care is finally getting some much-needed attention. Clinical documentation improvement (CDI) specialists, as a result, will play an important role in helping the healthcare system grapple with these complicated issues, according to Heather Greene, MBA, RHIA, CDIP, CPC, CPMA.
“This population needs us more than even acute-care patients—many of them can’t even meet their activities of daily living (ADLs),” Greene said Monday in her CDI Summit presentation “CDI in Mental Health.” “They need us to set them up for success so we really can’t have shabby documentation … CDI specialists and coders can’t give someone something [a diagnosis] they don’t have, because it follows them their whole life,” Greene said.
Tips for Mental Health Documentation Success
Greene said she keeps the following maxim in mind when working with coders in the mental health community: Coders are like peacocks—when you point out their flaws, their feathers grow up. Still, the nuances are important, meaning CDI specialists need to take their time in the following coding and documentation scenarios:
- Discerning the difference between “opioid dependence” and “longtime use of opioid medications.” An elderly individual who has taken opioids over a long period of time for spinal stenosis walked a different path than a person who takes opioids after an injury and becomes addicted. The government allocates resources for treating these circumstances differently, which must be reflected in documentation.
- In mental health coding, as opposed to acute care or physician coding, a physician may deliberately choose a “not otherwise specified (NOS)” code without getting a CDI query because they want to spend more time with a patient before they’re comfortable making a diagnosis. However, there are limits to the length of this evaluation. If an inpatient without a diagnosis code has an unusually long stay, a CDI specialist should know why.
- In inpatient settings where individuals can be undergoing treatment for multiple addictions, a distinction should be made as to whether the patient is experiencing nicotine withdrawal or alcohol withdrawal. Simply listing “withdrawal” is not specific enough.
- Newly diagnosed Alzheimer’s patients frequently experience severe clinical depression, which can worsen the dementia symptoms and result in inpatient psych stays. Documenting and treating early symptoms of depression can improve a dementia patient’s quality of life.