Can I include the diagnostic code for fibromyalgia for superbilling (super billing) purposes in psychiatry if it contributes to a patient's psychological stress, or should it only be included if I have diagnosed and am actively treating it?

Billing for Fibromyalgia in Psychiatric Practice

You should only include the fibromyalgia diagnostic code if you have personally diagnosed it using established criteria (widespread pain for ≥3 months plus tenderness at ≥11 of 18 tender points, or modified ACR 2010 criteria) and are actively addressing it in your treatment plan—simply acknowledging it as a stressor without diagnosing or treating it does not meet billing requirements for including the code. 1, 2

Billing Requirements for Diagnostic Codes

When You CAN Include the Fibromyalgia Code

• You have made the diagnosis yourself using ACR criteria: widespread pain in all four quadrants for at least 3 months, plus pain on palpation in at least 11 of 18 specific tender points 1, 2
• Alternative diagnostic approach: You can use the modified ACR 2010 criteria which focus on chronic widespread pain, sleep disturbances, and physical/mental exhaustion without requiring tender point examination 3
• You are actively treating the condition with interventions within your scope of practice, such as prescribing duloxetine, milnacipran, amitriptyline, or pregabalin for fibromyalgia symptoms 1, 4, 5
• You are providing psychotherapy specifically targeting fibromyalgia-related issues, such as cognitive behavioral therapy for pain management and mood disorders associated with fibromyalgia 6, 1

When You CANNOT Include the Fibromyalgia Code

• Another provider diagnosed it and you are only acknowledging its existence as contributing to psychological stress 2
• You are not actively treating the fibromyalgia with specific interventions, even if it impacts the patient's mental health 3
• You are only treating the psychiatric sequelae (depression, anxiety) without addressing the fibromyalgia syndrome itself 5, 2

Appropriate Billing Strategy for Your Scenario

Document the Relationship Without Inappropriate Coding

• Use your psychiatric F-codes (e.g., F41.1 for generalized anxiety disorder, F32.x for depressive disorders) as the primary diagnoses you are treating 5, 2
• Document in your clinical notes that the patient has a history of fibromyalgia diagnosed by another provider (specify who) and that this chronic pain condition contributes to her psychological distress 2, 7
• This documentation supports medical necessity for your psychiatric treatment without requiring you to bill for a condition you haven't diagnosed or aren't treating 7

If You Want to Treat the Fibromyalgia

You must take these steps to legitimately bill for it:

• Perform your own diagnostic assessment using ACR criteria, documenting widespread pain distribution and duration, tender point examination (or modified criteria), and exclusion of other causes 1, 2, 3
• Develop a treatment plan that specifically addresses fibromyalgia, such as prescribing duloxetine 60 mg daily (which treats both depression and fibromyalgia pain), amitriptyline 10-50 mg at bedtime, or pregabalin 1, 4, 5
• Provide patient education about fibromyalgia as a centralized pain condition and recommend exercise therapy as first-line treatment 6, 1, 4
• Document your rationale for choosing medications that address both psychiatric and fibromyalgia symptoms, as this represents appropriate integrated care 5, 8

Common Pitfalls to Avoid

• "Superbilling" with diagnoses you haven't made violates billing integrity and can constitute fraud, regardless of whether the condition impacts your patient's mental health 7
• Assuming psychiatric comorbidity justifies billing for fibromyalgia when you're only treating the psychiatric component—the high prevalence of depression and anxiety in fibromyalgia patients (up to 3-6 fold higher in women) doesn't mean treating the mood disorder equals treating fibromyalgia 2, 8
• Failing to document your diagnostic process if you do diagnose fibromyalgia—you must show you applied established criteria, not just accepted another provider's diagnosis 2, 3

Optimal Approach for Psychiatrists

Psychiatrists are actually well-positioned to diagnose and treat fibromyalgia because the most effective medications (duloxetine, milnacipran, amitriptyline, pregabalin) are familiar to psychiatric practice and often treat comorbid depression simultaneously 5, 8. If you want to include the fibromyalgia code:

• Conduct a proper diagnostic evaluation at your next visit, documenting pain distribution, duration, associated symptoms, and either tender point examination or modified criteria 1, 2
• Prescribe evidence-based treatment such as duloxetine 60 mg daily (FDA-approved for both fibromyalgia and depression) or amitriptyline 10-50 mg at bedtime 1, 4, 5
• Coordinate with the diagnosing provider to ensure continuity of care and avoid duplication of services 7
• Then legitimately bill for both conditions as you are actively managing both the psychiatric and fibromyalgia diagnoses 5, 8