Review these tips on how to properly document autism and other neurodevelopmental disorders

Health care providers’ accurate documentation of autism and other neurodevelopmental disorders is essential for optimal care coordination and risk adjustment accuracy. Clear documentation improves coding completeness, supports appropriate reimbursement and reflects patient complexity.

Below are important information and instructions, which providers can find in the 2025 Risk Adjustment Coding Guidance, to keep in mind when documenting these conditions.

Note: None of the information included here 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 all applicable state and federal laws and regulations.  

Key documentation elements

• Condition category
• Autism spectrum disorder
• Childhood disintegrative disorder
• Pervasive developmental disorder – Not otherwise specified

• Symptom details
• Impaired social interaction or communication
• Repetitive behaviors, fixated interests
• Delayed milestones or behavioral signs

Common pitfalls when documenting these elements include:

• Omitting severity or functional impact
• Documenting only symptoms without formal diagnosis
• Incomplete or vague documentation

Here’s an example of how correct documentation should look:

Patient with autism spectrum disorder, with significant difficulty in social communication, limited eye contact and repetitive speech. Requires substantial support at school. Diagnosis is supported by developmental history and clinical evaluation.

Medications

Review and identify medications in each patient encounter. For example, Risperdal^® is commonly used to treat schizophrenia and bipolar disorder. Providers are required to document this medication when prescribing it to treat autism.

See a couple of examples on how to document medications identified during a patient encounter:

•  Haldol^® for aggression, reviewed today and no refills at this time.
• Topamax^® for seizures, reviewed today, reference date of encounter.

Conditions

All associated medical conditions, such as epilepsy and developmental disability, must be reviewed in the patient encounter.

Here’s an example:

A child with a diagnosis of autism. The patient’s progress note also mentions having a language deficit. The correct code selection is F84.0, with a secondary code of R48.8 because of the underlying medical diagnosis contributing to the language problems. When medical etiology is not documented, only 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 submissions or to support a higher specificity ICD-10 code for autistic spectrum disorder or pervasive developmental disorder.

To recap, providers must address all conditions in the patient encounter and thoroughly document them in the medical record to help ensure coding accuracy and high-quality care.

Quick documentation checklist

• Use current autism spectrum disorder terminology
• Include symptom examples
• Describe functional limitations
• Clearly state diagnosis