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Discussion

Active diagnosis

[COLOR=#000000]Hello,

I have a patient with past medicalhistory of dementia with psychosis; however she did not receive any psychotropicmedication during the looking back period. The only medication she has ishaldol for psychosis which she did not receive during the looking back period. Under section I for dx I did code for dementiasince patient is confuse and her BIMS was 9 out of 15. I am just not sure if I shouldcode for psychosis too? [/COLOR]

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    Psychosis is a symptom. It is not the same as Psychotic Disorder which requires physician documentation. So psychosis alone is not coded in I. If you're referring to a more specific diagnosis in I8000 like Dementia w/ Behavior disturbance (psychosis), the condition must have been "active" in the last 7 days. Active does not necessarily mean the need to administer a psych med. Was there a behavior problem, presence of hallucination or delirium in the lookback? Is there an active care plan for behavior management?

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    Patient has history of dementia with disturbance behavior, however no behavior observed during the looking back period. Also in our facility They keep behavior in care plan they don't cancel it.

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    If there is no behavior issue coded in E and no hallucination or delirium identified, don't enter a dx for behavior disturbance. To be active it should be evidenced-base.

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    • Author

    Since no behavior, hallucinations,or delirium noted during the looking back period. I just entered the diagnostic of dementia (I4800)

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