How do I chart diagnostic codes for a patient with a reported history of depression, anxiety, panic attacks, attention-deficit/hyperactivity disorder, bipolar disorder, schizophrenia, obsessive‑compulsive disorder, and insomnia?

Diagnostic Coding for Multiple Reported Psychiatric Conditions

When a patient presents with a reported history of multiple psychiatric diagnoses (depression, anxiety, panic attacks, ADHD, bipolar disorder, schizophrenia, OCD, and insomnia), you must verify each diagnosis independently rather than simply transcribing the patient's self-reported history, as psychiatric diagnoses require clinical confirmation and many conditions are mutually exclusive or represent diagnostic hierarchy violations.

Critical First Step: Distinguish History vs. Active Diagnosis

• Never code a diagnosis based solely on patient report – the ICD-10-CM requires clinical verification and documentation of current symptoms meeting diagnostic criteria 1
• Code only conditions you can clinically substantiate during the current encounter through examination, review of records, or validated assessment tools 1
• For unverified historical diagnoses, use Z86.59 (Personal history of other mental and behavioral disorders) rather than coding active psychiatric conditions 1

Hierarchical Diagnostic Considerations

Rule Out Mutually Exclusive Diagnoses

• Bipolar disorder and schizophrenia cannot both be primary diagnoses – if psychotic symptoms occur exclusively during mood episodes, the diagnosis is bipolar disorder with psychotic features; if mood symptoms are brief relative to psychotic symptoms, consider schizoaffective disorder 2, 3
• Major depressive disorder cannot be coded if bipolar disorder is present – depressive episodes in bipolar patients are coded as bipolar disorder, current episode depressed 2
• Many of these conditions show high genetic correlation and may represent overlapping manifestations of general psychopathology rather than distinct disorders 3

Assess for Comorbidity Patterns

• Anxiety disorders (panic disorder, OCD, generalized anxiety) commonly co-occur with mood disorders, with panic disorder present in 36.8% of bipolar patients and 31.4% of unipolar depressives 4
• OCD shows 21.1% comorbidity with bipolar disorder and 14.3% with unipolar depression 4
• ADHD, anxiety, and depression frequently cluster together genetically and clinically 3

Systematic Verification Process

Step 1: Screen for Active Symptoms

• Use PHQ-9 for depression screening – scores ≥11 indicate likely major depressive disorder requiring further diagnostic evaluation 5, 6
• Never skip the suicidal ideation question (PHQ-9 item 9) – any endorsement requires immediate emergency psychiatric referral regardless of total score 5, 6
• Use GAD-7 for anxiety screening – scores ≥10 suggest moderate to severe anxiety requiring diagnostic assessment 7
• Apply validated tools rather than relying on subjective report alone 7, 8

Step 2: Rule Out Medical Causes

• Before coding any psychiatric diagnosis, exclude medical etiologies: uncontrolled pain, fatigue, delirium from infection or electrolyte imbalance, thyroid disorders, and medication side effects 7, 8, 5, 6
• Document that medical causes have been considered and excluded 7

Step 3: Establish Diagnostic Hierarchy

• If psychotic symptoms are present, determine whether they occur only during mood episodes (bipolar with psychotic features) or persist independently (schizophrenia or schizoaffective disorder) 2
• If manic episodes have ever occurred, code bipolar disorder rather than major depressive disorder, even if currently depressed 2
• If symptoms meet criteria for multiple anxiety disorders, code all that apply, as they frequently co-occur 4

Step 4: Verify Each Diagnosis with Specific Criteria

• Major depressive disorder requires ≥5 of 9 DSM symptoms for ≥2 weeks, with at least one being depressed mood or anhedonia, plus clinically significant functional impairment 8, 5
• Use HAM-D for severity classification: mild (7-17), moderate (18-24), severe (≥25) 7, 8
• Each coded diagnosis must have documented evidence meeting diagnostic criteria 1

Practical Coding Approach

For Verified Active Conditions

• Code each diagnosis that you have clinically confirmed with current symptoms and functional impairment 1
• List the primary diagnosis (most clinically significant or reason for visit) first 1
• Include severity specifiers when available (e.g., F33.2 Major depressive disorder, recurrent, severe without psychotic features) 1

For Unverified Historical Reports

• Use Z86.59 (Personal history of other mental and behavioral disorders) for conditions the patient reports but you cannot verify 1
• Document in the clinical note which specific historical diagnoses the patient reports 1
• Note that previous records or specialist evaluation will be needed for verification 1

For Insomnia

• Code insomnia separately only if it is not better explained by another mental disorder 2
• If insomnia is a symptom of depression or anxiety, it should not receive a separate code 2

Common Pitfalls to Avoid

• Do not code based on patient self-report alone – this violates ICD-10-CM coding guidelines and may constitute fraud if used for billing 1, 9
• Do not code mutually exclusive diagnoses (e.g., both bipolar disorder and major depressive disorder as active diagnoses) 2
• Do not overlook the need for emergency evaluation when suicidal ideation is present 5, 6
• Do not use "unspecified" codes when sufficient information exists for a more specific diagnosis 9
• Clinicians often use diagnostic codes primarily for administrative purposes (68.1%) rather than systematically applying diagnostic criteria (57.4%), but proper coding requires clinical verification 9