Coding corner: properly documenting autism spectrum disorder

As you’ve read in “Coding corner” articles in The Record before, proper clinical documentation is crucial to ensuring complete, consistent and accurate information about a patient encounter — and also for delivery of high-quality treatment and care.

Background
In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), released in 2013, the four autistic subtypes were combined under one umbrella diagnosis of “autism spectrum disorder,” also known as pervasive developmental disorder.

The coding assignment for this condition depends on accurate and thorough documentation in the medical record. It’s important that providers include some or all of the following detailed descriptions to achieve more accurate and specific documentation:

Condition category

• Autistic disorder (autism)
• Asperger’s disorder
• Childhood disintegrative disorder
• Pervasive developmental disorder — not otherwise specified

Symptoms

• Age of onset
• Clinically significant impairment in social, occupational and other crucial areas of current functioning

Severity level

• Requiring (substantial or very substantial) support
• Social communication impairments
• Restrictive patterns of behavior

Specificity

• With or without accompanying intellectual impairment
• With or without accompanying language impairment
• Associated with a known medical or genetic condition or environmental factor

Screenings/assessments/laboratory testing

• It’s necessary to document the results and any diagnosis in the medical record in the patient encounter. For example, MRI or electroencephalogram tests.

Medications

• Be sure to review and identify medications in each patient encounter. For example, Risperdal^® is commonly used to treat schizophrenia and bipolar disorder. Documentation is required to prescribe this medication to treat autism.
• Or Haldol^® for aggression, for example, reviewed today and no refills at this time.
• Or Topamax^® for seizures, for example, reviewed today, reference date of encounter.

In addition, it’s important that all associated medical conditions, such as epilepsy, mental retardation, tuberous sclerosis, etc., are reviewed in the patient encounter. Here are a few examples:

• A child with a diagnosis of autism. The progress note further mentions having a language deficit.
• An encounter for autistic spectrum disorder follow-up. Past medical history indicates the patient has tuberous sclerosis. The correct code selection is R48.8 because of the underlying medical diagnosis contributing to the language problems. When medical etiology is not documented, F80.2 should be assigned.

It’s equally important to evaluate all conditions mentioned in the patient encounter, including other impairment or behavior issues that could affect the current patient encounter and treatment. For example:

• An encounter for an autistic child with an upper-respiratory infection. In the History of Present Illness the provider refers to the patient as autistic but doesn’t assess the condition by itself or how it affects the treatment for the upper-respiratory infection.

A review of past medical history is important for overall patient care. Chronic conditions that are actively being treated should be assessed for diagnosis closure submission(s) or to support a higher specificity ICD-10 code for autistic spectrum disorder/pervasive developmental disorder. For example, a patient encounter for autistic spectrum disorder follow-up. The past medical history indicates the patient has tuberous sclerosis.

To recap, it’s important that all conditions are addressed in the patient encounter and thoroughly documented in the medical record to help ensure coding accuracy and high-quality care delivery.

None of the information included in this article is intended to be legal advice and, as such, it remains the provider’s responsibility to ensure that all coding and documentation are done in accordance with applicable state and federal laws and regulations.